By: Amanda Porter
In part of the Tanner Lectures Esther Duflo’s Lecture 1: Paternalism versus Freedom sets up a discourse, not about how to implement policy, but about the complexities and implications necessary to consider before attempting to craft and implement policy. Duflo’s piece brings up many important and controversial issues like the balance between exploitative paternalism and the “pull yourself up by your bootstraps” mentality and the critiques and merits of international aid as either an extension of colonial rule on one end or a necessary substitute for failed or missing state provision of resources on the other. Ultimately, the crux of Duflo’s first lecture is about which policies or interventions expand or limit freedom and specifically, how patneralism can both restrict and/or expand freedom, depending on how it is wielded and how freedom is defined. I will focus on the section related to Choices and the Environment, using the arguments in that section as a jumping off point to discuss scarcity in decision making and use the example of the Population Health Management infrastructure (part of the Affordable Care Act policy) to demonstrate the complexities around paternalism and barriers to choice for those living in poverty.
In her section of Choices and the Environment Duflo argues that “choice is not costless” and that “humans don’t have an infinite amount of those resources” so that ultimately when those in poverty have to spend time, energy and their human and intellectual capital making decisions that are crucial to basic needs like food, shelter and water; they have less capability or capacity to exert self-control or make the “right” choices on more ancillary, but still crucial life choices like education or health care (pg 17). According to a 2013 New York Times article, “Sendhil Mullainathan, a Harvard economist, and Eldar Shafir, a psychologist at Princeton, propose a way to explain why the poor are less future-oriented than those with more money. According to these authors, one explanation for bad decisions is scarcity — not of money, but of what the authors call bandwidth: the portion of our mental capacity that we can employ to make decisions.” The author goes on to explain that scarcity of mental capacity leads to poor decisions that contribute to the vicious cycle of poverty. On the other hand, as Duflo explains, not having to make choices about basic needs leaves the wealthy with more mental bandwidth to make choices that, for example, enhance their decision making skills and performance at work which increases their income earning potential which eases their financial constraints and on and on—setting them on the path of a virtuous cycle. Obviously this model overly-simplified and there are other factors at play in explanations of cycles of poverty. Just because a poor person is poor, does not mean that they will not practice good decision making or self-regulation and just because a person is wealthy does not mean that they are immune from setting themselves into a vicious cycle. However, there does seem to be some merit to the argument based on empirical evidence and psychological research experiments.
As a part of the Affordable Care Act rollout, in 2015 Mount Sinai Queens (MSQ) began to pilot a plan for support care management services for the underserved Medicaid population in Northwestern Queens, where there are deep pockets of poverty. The goal is to ultimately develop a Population Health Management infrastructure. The concept of the program is to target low-income, high risk Medicaid patients who frequently use the emergency room as their primary method of healthcare. Through a program called Health Homes, a team of health care professionals use a case management model to outreach and enroll patients. Once enrolled, patients receive holistic care and referrals to improve the healthcare, quality of life and well-being of this vulnerable population. Patients are identified “top down” from a list provided by the government and are also outreached to in real time with data provided from the emergency room of chronic ER visitors who are also on Medicaid. The patients targeted by this program are low-income, have one or more chronic illnesses and many struggle with long time drug addictions and face other issues like housing insecurity. Duflo explains that for those living in poverty, when making decisions they may not have knowledge of the benefit they are entitled to and the complexity of the administrative barriers seems daunting—therefore they choose status quo (pg 10). During this program pilot, the outreach team faced these issues. At first they tried a targeted mailing, explaining the program and that it was free and how to enroll; but that method garnered no response. Next, the outreach team followed up with calls, with little success. Ultimately, knocking on doors and explaining, in person, (sometimes more than once) the benefits of the program had the most success. It’s not to imply that this population is less intelligent, it’s just that a program administered and facilitated through Medicaid surely comes with government red tape and complicated language during enrollment. Especially with a new health care program and especially for people who are concentrating on making decisions that will keep a roof over their head while struggling with physical illness—the choice is not a simple one.
Similarly, Duflo argues that trust is a major factor to consider in the complexity of policymaking for low-income families—whether its trust of the government, the institution or the individuals implementing the policy (pg. 12). People being recruited for this program couldn’t understand why they were being offered a free program that would seek to holistically address their healthcare and social-emotional needs and why people they had never seen before were knocking on their doors to recruit them. For the MSQ Health Homes Team, it took partnering with local, trusted nonprofit organizations and institutions like churches in the community as well as multiple in person conversations to gain the trust of these patients. Finally, Duflo explains that, “small barriers that may appear to us to be minuscule in view of the likely benefits may be significant factors in the household’s decision-making” (pg. 10). For example, many of the patients enrolled in this MSQ program suffered from mental illness that was impeding their ability to seeks sustained medical care and take the steps they needed to not only treat their chronic illnesses, but to hold down a job and obtain stable housing and maintain a supportive family and social life. The team would continually provide referrals, but noticed patients were not following through. It turns out that there is a serious lack of mental health facilities in Northwestern Queens, and almost none that treated the Medicaid population. Therefore, patients had to take public transportation and leave their trusted communities in order to access this service. To Duflo’s point, a situation that seems like a nonissue for those not dealing with the many constraints of poverty was prohibitive for this population. Ultimately, the team identified this gap in care and sought to bring on an in house mental health expert to treat the enrolled patients all within the same team of care management, in order to increase the health and well-being of individuals in a way that was more realistic for those being treated.
Although Duflo’s argument is not a prescription for implementation of policy that can effectively break the cycle of poverty, as Rosenburg points out in her article “The scarcity phenomenon is good news because to a certain extent, we can design our way around it. Awareness of the psychology of scarcity and the behavioral challenges it yields ‘can go some way toward improving the modest returns of anti-poverty interventions,’ Mullainathan and Shafir write” (2013). However, even quotes like this from “experts” about the ways in which people in poverty make decisions can come off as paternalistic, or at least condescending. Therefore, even if some modicum of paternalism is necessary to provide people with their basic needs in order to expand their freedoms in other areas, it is important to be reflexive about the ways in which policy construction and its implementation is paternalistic towards the targets of that intervention.
Additional Sources
Rosenburg, Tina. 2013 “Escaping the Cycle of Scarcity.” The New York Times http://opinionator.blogs.nytimes.com/2013/09/25/escaping-the-cycle-of-scarcity/?hp&_r=1
In part of the Tanner Lectures Esther Duflo’s Lecture 1: Paternalism versus Freedom sets up a discourse, not about how to implement policy, but about the complexities and implications necessary to consider before attempting to craft and implement policy. Duflo’s piece brings up many important and controversial issues like the balance between exploitative paternalism and the “pull yourself up by your bootstraps” mentality and the critiques and merits of international aid as either an extension of colonial rule on one end or a necessary substitute for failed or missing state provision of resources on the other. Ultimately, the crux of Duflo’s first lecture is about which policies or interventions expand or limit freedom and specifically, how patneralism can both restrict and/or expand freedom, depending on how it is wielded and how freedom is defined. I will focus on the section related to Choices and the Environment, using the arguments in that section as a jumping off point to discuss scarcity in decision making and use the example of the Population Health Management infrastructure (part of the Affordable Care Act policy) to demonstrate the complexities around paternalism and barriers to choice for those living in poverty.
In her section of Choices and the Environment Duflo argues that “choice is not costless” and that “humans don’t have an infinite amount of those resources” so that ultimately when those in poverty have to spend time, energy and their human and intellectual capital making decisions that are crucial to basic needs like food, shelter and water; they have less capability or capacity to exert self-control or make the “right” choices on more ancillary, but still crucial life choices like education or health care (pg 17). According to a 2013 New York Times article, “Sendhil Mullainathan, a Harvard economist, and Eldar Shafir, a psychologist at Princeton, propose a way to explain why the poor are less future-oriented than those with more money. According to these authors, one explanation for bad decisions is scarcity — not of money, but of what the authors call bandwidth: the portion of our mental capacity that we can employ to make decisions.” The author goes on to explain that scarcity of mental capacity leads to poor decisions that contribute to the vicious cycle of poverty. On the other hand, as Duflo explains, not having to make choices about basic needs leaves the wealthy with more mental bandwidth to make choices that, for example, enhance their decision making skills and performance at work which increases their income earning potential which eases their financial constraints and on and on—setting them on the path of a virtuous cycle. Obviously this model overly-simplified and there are other factors at play in explanations of cycles of poverty. Just because a poor person is poor, does not mean that they will not practice good decision making or self-regulation and just because a person is wealthy does not mean that they are immune from setting themselves into a vicious cycle. However, there does seem to be some merit to the argument based on empirical evidence and psychological research experiments.
As a part of the Affordable Care Act rollout, in 2015 Mount Sinai Queens (MSQ) began to pilot a plan for support care management services for the underserved Medicaid population in Northwestern Queens, where there are deep pockets of poverty. The goal is to ultimately develop a Population Health Management infrastructure. The concept of the program is to target low-income, high risk Medicaid patients who frequently use the emergency room as their primary method of healthcare. Through a program called Health Homes, a team of health care professionals use a case management model to outreach and enroll patients. Once enrolled, patients receive holistic care and referrals to improve the healthcare, quality of life and well-being of this vulnerable population. Patients are identified “top down” from a list provided by the government and are also outreached to in real time with data provided from the emergency room of chronic ER visitors who are also on Medicaid. The patients targeted by this program are low-income, have one or more chronic illnesses and many struggle with long time drug addictions and face other issues like housing insecurity. Duflo explains that for those living in poverty, when making decisions they may not have knowledge of the benefit they are entitled to and the complexity of the administrative barriers seems daunting—therefore they choose status quo (pg 10). During this program pilot, the outreach team faced these issues. At first they tried a targeted mailing, explaining the program and that it was free and how to enroll; but that method garnered no response. Next, the outreach team followed up with calls, with little success. Ultimately, knocking on doors and explaining, in person, (sometimes more than once) the benefits of the program had the most success. It’s not to imply that this population is less intelligent, it’s just that a program administered and facilitated through Medicaid surely comes with government red tape and complicated language during enrollment. Especially with a new health care program and especially for people who are concentrating on making decisions that will keep a roof over their head while struggling with physical illness—the choice is not a simple one.
Similarly, Duflo argues that trust is a major factor to consider in the complexity of policymaking for low-income families—whether its trust of the government, the institution or the individuals implementing the policy (pg. 12). People being recruited for this program couldn’t understand why they were being offered a free program that would seek to holistically address their healthcare and social-emotional needs and why people they had never seen before were knocking on their doors to recruit them. For the MSQ Health Homes Team, it took partnering with local, trusted nonprofit organizations and institutions like churches in the community as well as multiple in person conversations to gain the trust of these patients. Finally, Duflo explains that, “small barriers that may appear to us to be minuscule in view of the likely benefits may be significant factors in the household’s decision-making” (pg. 10). For example, many of the patients enrolled in this MSQ program suffered from mental illness that was impeding their ability to seeks sustained medical care and take the steps they needed to not only treat their chronic illnesses, but to hold down a job and obtain stable housing and maintain a supportive family and social life. The team would continually provide referrals, but noticed patients were not following through. It turns out that there is a serious lack of mental health facilities in Northwestern Queens, and almost none that treated the Medicaid population. Therefore, patients had to take public transportation and leave their trusted communities in order to access this service. To Duflo’s point, a situation that seems like a nonissue for those not dealing with the many constraints of poverty was prohibitive for this population. Ultimately, the team identified this gap in care and sought to bring on an in house mental health expert to treat the enrolled patients all within the same team of care management, in order to increase the health and well-being of individuals in a way that was more realistic for those being treated.
Although Duflo’s argument is not a prescription for implementation of policy that can effectively break the cycle of poverty, as Rosenburg points out in her article “The scarcity phenomenon is good news because to a certain extent, we can design our way around it. Awareness of the psychology of scarcity and the behavioral challenges it yields ‘can go some way toward improving the modest returns of anti-poverty interventions,’ Mullainathan and Shafir write” (2013). However, even quotes like this from “experts” about the ways in which people in poverty make decisions can come off as paternalistic, or at least condescending. Therefore, even if some modicum of paternalism is necessary to provide people with their basic needs in order to expand their freedoms in other areas, it is important to be reflexive about the ways in which policy construction and its implementation is paternalistic towards the targets of that intervention.
Additional Sources
Rosenburg, Tina. 2013 “Escaping the Cycle of Scarcity.” The New York Times http://opinionator.blogs.nytimes.com/2013/09/25/escaping-the-cycle-of-scarcity/?hp&_r=1