Category: Nathaniel Counts

Rational Actors and Happy Actors

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By Nathaniel Counts

Politics, theoretically at least, is a process designed to enhance the sense of wellbeing of its citizens.  The success of this process, the amount of wellbeing that can be created, is hamstrung by biology – we have basal levels of felt wellbeing that are determined through some amount of nature and nurture, and that are independent of our present circumstances.  Because there is a biological component to it, we may be able to alter an individual’s basal wellbeing before they reach adulthood.  For example, if hypomania, a psychological condition where the individual only experiences the manic part of bipolar disorder, were found to have a definitively genetic etiology, gene therapy could be used on embryos so that they would grow up to experience the constant heightened state of wellbeing associated with the condition (for an interesting article on hypomania and wellbeing, see here).

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Health Class and Personal Preferences

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By Nathaniel Counts

High school health classes that are effective in preventing high-risk behaviors employ two educational models: the social influences model and the life skills model.  The social influences model teaches children about social norms and techniques for resisting social influences.  The life skills focuses on developing child autonomy, self-esteem, and self-confidence to help children resist social influences and gain a sense of self.  There are two explanations for why health classes premised on these models would be effective: either they replace the preferences the children were likely to develop with different preferences or they help children develop their own preferences which, for some reason, consistently disfavor high-risk behaviors.

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Admissions and Mental Health

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By Nathaniel Counts

In our legal system, colleges may not make admissions decisions in order to ameliorate historical (or presumably other) inequalities, but may make decisions that take into account the particular situation of the applicant or that strive to create a diverse student body.  Justice Powell rejected the former two goals in Part IV of his Bakke opinion, which went uncontradicted in the Grutter opinion that followed it and, most recently, the Fisher opinion almost exclusively focused on the diversity justification.  Whether or not it appears in court opinions however, the issue of transformative justice is very much at stake – colleges, as the gatekeeper to many of the high honors and offices of our society, can control the distribution of a set of goods to the rising generation and decide how equally they are distributed among certain groups.  Here we will imagine that transformative justice is indeed the goal of affirmative action.

Colleges have two tools by which they can currently select among students based on disadvantage (historical or otherwise).  First, there is the demographic and socioeconomic information disclosed in the application.  Although these questions are optional, for those students who answer the questions, schools may use these answers as signals for disadvantage and take this into account.  Second, there is the essay questions, which frequently ask about an instance in which the applicant overcame adversity.  Here the applicant can demonstrate the degree of disadvantage experienced or explain some more nuanced disadvantage not revealed in the first part.

These two tools are far from perfect, but let us take our imagining further and envision a world in which colleges could accurately determine disadvantage.  If it decides to take on the latter, mental health may pose an insurmountable problem – individuals with intellectual disabilities may not be able to thrive in the setting offered by the institutions that select them.

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Diagnosing Mental Disorders from Internet Use

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By Nathaniel Counts

We live in a time when increasingly our personal information is publicly available on the internet.  This personal information includes our names and phone numbers, things we’ve written and things we’ve done, along with a good deal of information that only exists because we interact with others on the internet – thoughts that we might not have otherwise externalized, or that we certainly would not have saved so that others could read.

If all of this information is publicly available, all of this information can be gathered.  Already advertisers analyze our behaviors to better target products to us.  It is not hard to imagine a not so distant future where the government analyzes this data to determine whether we have a DSM mental disorder.  By looking at the online behaviors of those already diagnosed – the way the syndrome affects their usage patterns, the sites they visit, and how they interact with others online – it is likely that one can find statistically significant usage patterns that can distinguish individuals with a diagnosis from those without.  The available data could then be mined to identify other individuals that exhibit the usage pattern and allow for presumptive diagnosis.

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Social Signaling and the Undoing of the Harm Principle

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By Nathaniel Counts

In On Liberty, John Stuart Mill asserted that “[t]he only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.”  This has since become known as the harm principle and is foundational for much of American political discourse, especially for libertarianism and civil rights.  At the time of Mills’ writing, On Liberty having been published in 1859, this logic could protect a lot of conduct that involved consenting adults or did not appear to directly impact others.  If the harm principle was controlling, we could never have a soda ban.  Today however, with our advances in social science, clear lines of harm and no harm have become fuzzy.

Few people buy cigarettes in a vacuum.  Someone offers you cigarettes or you see other people smoking and then you buy cigarettes.  This phenomenon, in which we make decisions based on the decisions of others in relationship to our esteem for them (if we see someone we respect smoking, we will be more likely to smoke; if we see someone we do not respect smoking, we will be less likely to smoke) is called social signaling (The Origin, Development, and Regulation of Norms is a great article on a related topic, the generation of norms, which explains this phenomenon quite well).

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Potato Chips and Choice Architecture

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By Nathaniel Counts

If, out of concern for public health, the government banned potato chips today, a lot of people would get very angry.  Only some of these people would be angry because they missed potato chips.  For most it would be the principle of the thing – the government should not interfere with our autonomy to eat whatever we want, as long as it does not harm others, and some days this will include potato chips.  I would posit that the autonomy at issue here is a narrow understanding of autonomy, and one that we should be suspicious of.

Imagine yourself in the biggest Costco in the world.  It has every food in existence and they are all placed equidistant from you, and you may survey the scene and choose whatever food you most desire and then eat it.  This would be true autonomy.  The world we live in, however, is deeply constrained and we should question how meaningful our autonomy is.

In reality, every time someone who came to the Costco before you made a purchase, the store owners moved the product a little bit closer to you, and manufacturers began shipping more variants of it.  The decisions that determined the composition of your commercial world were made over hundreds of years by individuals with no understanding of health – diet and exercise, hypertension and heat disease all being foreign concepts until recently.  Today potato chips, in all their variety, take up quite a lot of shelf space, and healthful foods are hard to come by.

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Prioritizing Parks and Patients

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By Nathaniel Counts

During the government shutdown in October 2013, a battle in part over the future of healthcare reform, a non-negligible amount of media attention focused on the shutdown of public parks.  Perhaps because the parks were the least expected casualty of the shutdown, or the most ludicrous – many are, after all, large outdoor spaces that functioned for millions of years before there were federal funds for them – Americans were frustrated or amused that they could not walk around outside some places because politicians in D.C. could not agree on a budget.

The healthcare reform debate pitted those who believed that everyone should have health insurance or that access to healthcare was a right against those who believed that health spending was already too high or that everyone does not have a right to access to healthcare.  In a world of infinite resources, where everyone could have complete access to healthcare without anyone having to give up anything of their own, it is difficult to imagine that anyone would say that there should not be universal access to healthcare, that some are not deserving of the service.  It would be strange to require a threshold public showing of effort to obtain health insurance through employment if there was no cost to giving the healthcare – if fairness is an issue, as it appears to be a concern for some, there are certainly other services that could be denied.  It is likely that for most the fairness concern only becomes salient in the face of resource constraints where these same funds could fund other programs or allow others to pursue their interests.

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Managed Care for Mental Health

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By Nathaniel Counts

Managed care and integration of primary care and mental health services are major foci of the Affordable Care Act, especially as more practices are encouraged to become Patient-Centered Medical Homes.  In managed care, vitals are used to track progress, and case managers can look over an individual’s blood pressure, weight, and blood-sugar levels to work with service providers and patients to ensure best outcomes.  If an individual is receiving mental health services, then the providers will share information about the patient’s current needs in both physical and mental health.  If the individual is not referred to or does not seek out mental health services, then there is no mental health component to manage.

Meanwhile in Massachusetts, every pediatrician is mandated to offer CANS (Child and Adolescent Needs and Strengths), a lengthy evaluation form that asks a patient (aged 5 to 20 for the link above) to evaluate their own life and mental health on sets of 0-3 scales.  CANS is used to monitor children’s mental wellbeing and identify potential problematic areas, including whether a mental health referral for serious emotional disturbance is necessary.  To the best of my knowledge, this information is not stored and used as an indicator for managed care, as blood pressure and weight are. Read More

Managing All Care

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By Nathaniel Counts

Health insurers are beginning to realize the importance of downstream cost-saving.  By paying to keep people healthy now, health insurers avoid major expenditures later when they must cover chronic conditions and hospitalizations.  For example, by paying for nutrition counseling and fitness programs for prediabetics, health insurers can reduce the rate of transition to diabetes for their clients, which both saves the insurer thousands of dollars and keeps their clients happier and healthier.   This type of innovation is possible because the law requires certain expenditures, i.e. doctors must treat individuals at the emergency room, and these expenditures tend to be quite large if incurred.

Social services in general could enjoy this type of innovation if funding were pooled between government services, and healthcare, housing, food, and direct welfare were all managed together.  Currently, each is conceived as a separate welfare program, so one can only recognize reduction within a program, not how the programs interact.  For example, it may be that the expansion of SNAP benefits would decrease emergency room visits and end up being cost-saving overall.  It may also be that certain types of subsidized housing reduce the need for other services and are more cost-saving than others, but this is hard to recognize when each program is segregated.  One could imagine that subsidized housing built in areas with better access to quality food and jobs would be more expensive upfront, but could save in money overall by reducing the need for other benefits.  Because social services currently have a system of mandatory spending in the form of entitlements, there is an incentive to ensure that individuals transition away from use of the more expensive services.

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Only a Right to Health

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By Nathaniel Counts

Human rights disaggregates otherwise related issues into separate rights.  We discuss rights to health, education, housing, association, etc., and, in countries where these rights are codified, we litigate each one separately in the courts.  We also know that each of these issues for which there is a corresponding right is, to some extent, a symptom of poverty.  In some cases it might not be possible to treat the symptoms without addressing the root cause.  For example, in 1966, the Coleman study on equality in education found that “[s]chools bring little influence to bear on a child’s achievement that is independent of his [or her] background and general social context.”  These findings have been contested, but it is likely that socioeconomic factors are a determinant of a child’s academic success, along with the educational experience itself.  If the socioeconomic background is the greater determinant, it may not make sense to use scarce government resources to fund school improvement rather than addressing poverty itself.  In a country with a right to education, school improvement could be litigated and potentially derail national efforts to address root causes.

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