December 17, 2021
Dear Interested Readers,
Collective Action Problems. Healthcare Is Definitely On The List
Recently, the weather has been warmer, and I have enjoyed returning to my old routine of walking daily. I don’t know how long it will be possible. Every day without ice on the road is a gift even if it probably is the upside of global warming. While I walk, I often listen to a podcast. Earlier this week, as I was listening to podcasts, I heard a term, “a collective action problem,” that was new for me.
My education in economics, philosophy, and sociology has been mostly acquired through paths of personal discovery. My undergraduate education was a traditional premed program, and these were not subjects that got any airtime when I was in medical school. My ears perked up with the opportunity to learn something new when the speaker began to talk about “a collective action problem.”
If the term is new for you, the definition in Wikipedia is:
Even with that very spare definition, it seems to me that almost all the problems that face us as a society, including achieving equity in healthcare, defy resolution because of our problems acting collectively. Our current social, environmental, and political issues seem impossible to solve because of the “conflicting interests” that are the source of what we call our “partisan divide.” The description of collection action problems goes further and includes the difficult situation where what might be best for the community conflicts with what an individual or group might feel is in their immediate best interest. Congress is riven by its collective action problems. Consider President Biden’s “Build Back Better” bill. It is hard to deny that it contains many benefits for the majority of our citizens, but the super-wealthy, corporations, and those who benefit from the continued use of fossil fuels, like Senator Joe Manchin, see it not to be in their immediate best interest.
Problems arise when too many group members choose to pursue individual profit and immediate satisfaction rather than behave in the group’s best long-term interests.
The great seventeenth and eighteenth-century philosophers, Thomas Hobbs and David Hume understood the issues that created collective action problems and attributed much of the difficulty to the “natural state” of humans. We are a very social species, but within that generalization, there are qualifiers and exceptions. We are also self-interested and can be more interested in our immediate personal comfort and pleasure than in the long-term benefits that the whole group might gain through collective action.
Originally we lived in small family and tribal groups where collectively we could do more than as individuals. Through our ability to take collective actions toward common goals we separated ourselves from other species. If an alien from outer space were to visit our planet, it would be puzzled and find it difficult to understand why we have problems with collective action since history has shown that when we work together most of us can be richer, safer, better fed, healthier, and happier than we are when we are acting alone.
Collective action is the foundation of the accomplishments that create “non-zero” opportunities. Non-zero actions allow both sides to win. When we function in a non-zero mode, happiness increases for all parties. Despite the benefits of collective action and non-zero strategies we tend to view the world with a zero-sum outlook. In a zero-sum world, any advantage I gain is your loss. In a non-zero world, all of us win. In a non-zero world, collective actions create material capital, social capital, and more opportunity for both of us. One of my favorite books is the 2000 classic by Robert Wright, Nonzero: The Logic of Human Destiny. In that book, Wright discusses all the benefits of collective action and makes the connection between non-zero efforts and game theory.
Back in the mid-1600s, Thomas Hobbs identified sources of human strife that undermined the more positive potential benefits of collective action. The Wikipedia article on collective action problems quotes from his 1651 book, Leviathan:
“…if any two men desire the same thing, which nevertheless they cannot both enjoy, they become enemies.”
The discussion pointed out (The bolding is my addition):
Hobbs believed that the state of nature consists of a perpetual war between people with conflicting interests, causing people to quarrel and seek personal power even in situations where cooperation would be mutually beneficial for both parties. Through his interpretation of humans in the state of nature as selfish and quick to engage in conflict, Hobbes’s philosophy laid the foundation for what is now referred to as the collective action problem.
When people mention Hobbs from the seventeenth century they frequently finish their discussion by quoting the eighteenth-century Scottish philosopher, David Hume. Wikipedia continued its introduction of collective action problems with Hume’s take on the subject:
David Hume provided another early and better-known interpretation of what is now called the collective action problem in his 1738 book A Treatise of Human Nature. Hume characterizes a collective action problem through his depiction of neighbors agreeing to drain a meadow:
Two neighbours may agree to drain a meadow, which they possess in common; because it is easy for them to know each other’s mind; and each must perceive, that the immediate consequence of his failing in his part, is, the abandoning the whole project. But it is very difficult, and indeed impossible, that a thousand persons should agree in any such action; it being difficult for them to concert so complicated a design, and still more difficult for them to execute it; while each seeks a pretext to free himself of the trouble and expence, and would lay the whole burden on others.
So Hobbs says that we undermine the positive benefits of collective action because by nature we are selfish, greedy, and hungry for power. According to Hobbs, self-interest is a wet blanket or the real problem that blocks collective action. Hume chimes in by saying that the likelihood of collective action decreases as the size of the group increases.
Hume’s example may not seem profound or be all that obvious from his eighteen-century vernacular, but he is confirming Hobbs’ concept of competing interests and is also identifying the problem of “free-loaders” that create a big problem for collective action. The bigger the group that could benefit from a collective action the greater the likelihood that competing interests will arise and even when progress is made there will be people who benefit but never contributed. We all suspect that there are those among us who are delighted to benefit from the collective gain and are also quite comfortable letting others do the real work.
Fifteen years ago Don Berwick proposed collective action to improve healthcare when he offered us the Triple Aim. He tried to resolve our previous collective action issues by introducing us to the “tragedy of the commons” as he sought to motivate us to improve quality and eliminate the waste that increased the cost of care. Berwick was influenced by the concept of the “tragedy of the commons” which Garret Hardin described. Hardin saw that the lack of collective action and the pursuit of self-interest could lead to the destruction of a common asset like a system of healthcare. Hardin’s view was a bit Hobbsian with an element of Hume if you multiply the process of medical waste across a system that is as vast as American healthcare. Berwick was encouraged by the Nobel Prize-winning work of Elinor Ostrom that suggested ways in which humans could use rules and agreements to facilitate collective action and avoid the “tragedy of the commons.” Berwick believed that the Triple Aim was possible through collective action.
Theoretically, Berwick was right, if the quality of care has six components: patient-centeredness, safety, equity, timeliness, efficiency, and effectiveness; then it will surely take collective action to improve the quality of care enough to achieve the Triple Aim of better healthcare for the individual in healthier communities for a sustainable cost. Berwick envisioned that the natural professionalism in healthcare could be coupled with our collective interest in achieving universal access to care could be channeled to create the improvements in our system of care that would make the Triple Aim reality in our time. He also envisioned that the achievement would be fostered through improved public policy. He was counting on the commitment of all healthcare professionals and institutions to the six aspects of quality, including equity, that would overcome the problems of collective action and move the Triple Aim from just a vision and an impossibility to reality. I totally bought his theory and the possibilities for improvement that it fostered. In 2006 we were encouraged by the growing influence of the Institute for Healthcare Improvement and the passage of Romney Care in Massachusetts that gave 98% of citizens access to care. It was a heady time that paid little attention to the warnings of Hobbs and Hume. The very title of this blog, Strategy Healthcare, is derivative of the belief that there were collective actions that constituted integrated strategies that might accomplish what Berwick believed was possible, and what people consistently say they want. I still must believe in the possibility that someday we will achieve the Triple Aim. Perhaps, because of collective action problems, it is just a very long journey.
I have come to believe that many of our collective action endeavors share the same collective action problems that Hobbs and Hume theorized about several hundred years ago. They also share the reality that they impact the health of the nation and impede the accomplishment of the Triple Aim. Let me offer several examples. The social determinants of health are hard to improve and healthcare disparities will persist without collective political and social actions. Global warming has obvious collective action problems and is a huge potential public health issue. Gun violence is a deadly pandemic like deaths from drug overdoses that are also public health problems that fester because of collective action problems. There are non-zero actions that could be applied to each of these problems if competing interests could be managed. In my description of non-zero systems, I did not mention that non-zero can also yield a “lose-lose” outcome although we would prefer to think win-win.
Perhaps, our most current and potentially dangerous collective action challenge is our domestic and international management of COVID. As Hobbs would point out we have competing interests. There are those who want to be vaccinated and those who don’t. There are those who see a political opportunity to gain power by using the pandemic to create controversy, and those who see that without concerted efforts to address the virus with our best science the number of deaths will continue to climb. There are those who see a business opportunity while others see a rolling community disaster. As Hume would note, we have large numbers, the population of the whole world, which increases the opportunities for those who are self-interested. Hume also warned us of freeloaders. If we don’t have freeloaders in our attempts to control the spread of the virus, we do have those who sit on the sidelines just hoping that the nightmare will end without them having to do so much as wear a mask when in an indoor environment with many other people.
To make timely progress on all of our problems which can’t be corrected without community action things need to change. Both the far left and the far right vie for control because they share a similar fantasy of forcing others to their will. They have lost patience with the search for workable compromises. They have abandoned the process of compromise that has served us well for almost two hundred and fifty years. The actions from both of the far ends of the political spectrum seem to suggest that both extremes feel that it is in their best interest to silence the other side by any means and control the process through coercive tactics. I don’t think that I am an alarmist, but I see only three possible outcomes from our unresolved collective action problems that require action to avoid shared misery. It is possible that everyone could see the light and be willing to look for win-win solutions to our healthcare challenges, the threat of global warming, and increasing inequity or if you prefer persistent poverty that will doom millions of children to lives of continuing misery. Another possibility is that one side or the other will seize the moment through some series of events that defy our Constitution and the norms of our society. The third possibility is that we will continue the stalemate of our divided state while our problems with collective action persist until one reaches a level of disaster that harms us all even more than COVID has, or global warming has the potential of doing.
In his 2019 book, The Second Mountain: The Quest for A Moral Life, David Brooks describes the societal shift that followed the Civil Rights movement of the fifties and sixties and the disappointments of Vietnam. The shift was from the collective search to improve our lives together as a community to a focus on individual objectives. Whether or not you agree with Brooks that the “Baby Boomer” generation devolved to the “Me generation” it is possible to imagine that the shift in focus from the collective to the interest of individuals has had some role in the creation of the political stagnation and national decline that has slowly occurred over the last fifty years. It is hard to deny that we are all very focused on what we perceive as our own best interest rather than the larger and safer benefits of being part of a society that desires the best possible health and the greatest possible happiness for everyone.
I was delighted to discover that this week Brooks was the guest host of Ezra Klein’s weekly podcast. Brooks chose to interview Leon Kass who had been one of his professors many years ago at the University of Chicago. Brooks asserts that Kass was the first person he ever interviewed for an article. I had never heard of Kass but he has had a remarkable history. He received his MD from the University of Chicago in the early 60s. He did his post-grad training at the Beth Isreal Hospital in Boston before starting work on a PhD. in biochemistry at Harvard. While working on his PhD., he went to the South to live and work with African Americans during the struggle for Civil Rights.
After his Civil Rights experience, he became interested in ethics and bioethics and taught these subjects at the University of Chicago with his wife using the collected wisdom expressed in literature including the works of the great philosophers and the Hebrew scriptures as foundational sources. He served on the President’s Council on Bioethics from 2001 to 2005. His books have titles like Founding God’s Nation: Reading Exodus and Leading a Worthy Life: Finding Meaning in Modern Times. Those titles and the fact that he is now a fellow at the American Enterprise Institute suggest that his views are traditionally conservative delivered with the honesty of classical liberalism as formulated by John Stuart Mill.
Toward the end of their conversation which I imagine has been occurring off and on for about thirty five years, Brooks brings up his idea from the Second Mountian.
David Brooks:
And I would say maybe around the ‘60s …we became just a much more individualistic culture. We came to define freedom as absence of restraint. And on the right, that led to an economic freedom, which is individualistic. I should be free to have my own property and my own economy the way I want it to be. And I want to be a heroic entrepreneur. On the left, it was a little more lifestyle freedom. I should be able to live the way I want to live without anybody watching over me. And that was probably needed, because we needed to break free from some of the conformity and constriction that existed, let alone the racism and the sexism and the anti-Semitism that existed.
But we’ve taken it a little too far. And so we sort of overdone it on individualism. And we’ve seen the loss of social capital, the loss of community, the loss of friendship, things I do not understand but are going on in the country. The rising number of people who say they have no close friends. Over half the country saying no one knows me well. The number of people who have ruptures in their nuclear families. Just a breakdown in connection across a wide array of social indicators. So that, to me, is a sociological problem that led to a formative problem.
Do you have any hope that we can recreate community, recreate institutions that we have faith in, that we’re willing to submit to in order to be formed by them? How deep is the despair here?
I won’t give you the entirety of Kass’ response, but below is the meat of it. In short, I would say that he sees a long and difficult road ahead and that he advises using some of the wisdom that has come down to us from the past as a guide to how to live together and diminish our problems with collective action.
Leon Kass:
One doesn’t want to sound like a grumpy old man by saying everything has gone to hell and it was much better in the old days. It’s a temptation of people my age. [He is 82.] But sometimes the evidence is strong. And one has to be very, very worried at the present time if one cares about a robust, unified national society and culture.
We’re living in an acutely angry time. And in the short run, I don’t know how that can be turned around. But the way back has to be really to return to some of the sources not as finely authoritative for us and solve our present problems. But they are our intellectual, cultural, and moral inheritance.
And so it seems to me the task is largely a matter of education. It’s a question of partly not tearing down the country and looking only at its faults and its warts, but remembering and not taking for granted the extraordinary blessings that one has living here, including the freedom to tear down and belittle the institutions that give us that right.
That response struck me as profound. It actually is consistent with Brooks’ concepts in The Second Mountain elevated from the individual to the collective. In the book, Brooks observes that we spend a lot of time in our individual lives “becoming.” Often after “becoming” we experience a change in fortune or circumstance that brings us down or causes us to reconsider the trajectory of our life. In that period we are off the “first mountain” and often in a valley of despair. Brooks offers us redemption and personal growth in the form of a “second mountain” where we move from being self-absorbed with becoming to being involved in meaningful pursuits. It may be a stretch but what has happened to us as a nation over the last fifty years is a painful descent from that first imperfect national mountain where we denied many Americans the full benefits of citizenship, sought to deny the horror of slavery, perpetuated policies that created increasing inequity, and continued the injustice experienced by many different minorities because of the expense and effort it would take to make things right. I think that Kass and Brooks suggest that we could choose to climb a second mountain drawing on lessons we may have learned as we ponder our predicaments, and using some of the wisdom we can find in the better parts of our collective past. It is a great thought for this season when we talk about the eternal benefits of peace, love, giving, and hoping.
We do have several society-threatening collective action problems, but we are not obligated to act like Hobbs and Hume predicted. We could choose to do better. As we try to do better, we may regain the energy we have lost in our efforts to use collective action to achieve the Triple Aim in a way that gives hope to our efforts to solve the other complex issues that face us.
Approaching Holidays And Serendipity In Strange Times
In just a week many children will go to bed with some version of “visions sugar plums” dancing in their heads. As a child, I never needed visions of sugar plums to be excited on Christmas Eve. In those days any vision I had was about what might be coming my way. I will be sending my next letter to you on Christmas Eve. I will be hitting send in California where my wife and I will be enjoying the holiday with our two young grandsons and their parents.
Until last Christmas when COVID prevented all travel, a typical Christmas for us was having everyone who could come to our house. We can sleep at least twelve visitors which makes us sort of like a small B&B. We planned it that way, and even this year it might have been possible except that our youngest grandson is not yet eligible for vaccination, and New Hampshire is still a COVID “hotspot”. We lost our “first in the nation” COVID ranking to Rhode Island a couple of days ago, but we are still number two. So, we will travel to California where more people are vaccinated and fewer go nuts when asked to wear a mask.
Earlier this week, before I wrote this letter, even before I heard Brooks’ podcast with Leon Kass, I was looking for an interesting scene for this week’s header. I have given you many pictures in the past of Mount Kearsarge and Mount Sunapee, the two tallest mountains near me. There is a state park, Winslow State Park, on the north side of Kearsarge with a parking lot, picnic areas, and playground equipment that is located at the trailhead of the vigorous one-mile hike to the summit. Since Tuesday was a very nice day I decided to drive up to the park to give you a picture from Mount Kearsarge rather than another picture of Mount Kearsarge. Because of the late afternoon sun, I could not shoot west toward Mount Sunapee. I could see a long way to the north, and could look down on Pleasant Lake as you can see in the picture below.
I could also see further north toward Killington in Vermont and thought I could even see the White Mountains fifty miles away, but the view I liked best was eastward toward Ragged Mountain, a mountain which never gets much attention from me.
When I took the picture I wasn’t looking for a modest little mountain as a visual representation of the second mountain that I hope our country might climb if it can find a way to overcome its collective action problems, but here it is. Sometimes good things happen even through serendipity when we don’t fully appreciate the opportunity of the moment. There is a little hope in that observation. It is the season of hope.
Be well,
Gene
Enjoy your trip, family and Holidays!
Dan & Holly