Monday, March 14, 2005

Putting the Puzzle Together, Part 1

In preparing for a speech I’ll be giving soon about some of the dilemmas of higher ed, it hit me that higher ed and health care are similarly positioned, and facing many of the same issues.

Both are, at their core, labor-intensive. Doctor with patient, teacher with student. Both have endured tremendous infusions of technology, with their varying costs and mixed blessings. Both have been on the receiving end of de-professionalizing trends: HMO’s and managed care treading on the autonomy of doctors, and adjunct-ification treading on the academic freedom and security of the professoriate. Both have attracted unflattering public attention due to rising cost. (In fact, a non-trivial portion of the rising cost of higher ed reflects the rising cost of health insurance.)

In both cases, and contrary to almost every other industry, technology has moved in without so much as a nod towards economic efficiency. In the case of medical care, advanced technologies improve the quality of care, albeit at tremendous cost. The public gripes mercilessly about the cost, but refuses to entertain any serious conversation about reducing access or quality. (Much of the rhetoric directed against single-payer health care revolves around the bugaboo of ‘rationing,’ as if the market doesn’t already do that.) In the case of higher ed, we adopt new technologies because the industries for which we prepare students have adopted them, whether they save us any money or not (and they almost never do). For example, the photography program in my division has had to make major purchases to adapt to the onset of digital photography, but it can’t just stop working with film. It has to support both. Therefore, we purchase digital cameras, high-end computers, and advanced software, and still purchase enlargers, darkroom curtains (fireproofed, naturally, at additional cost), and the traditional trappings. Do we get better outcomes? Yes and no; we get a student ready to enter the field, just like we did before. It just costs twice as much, and those rising costs are taken as evidence that academics are lazy and out of touch.

Tuition has been rising more slowly than health-care costs, probably because the pace of technical advance has been slower and the costs of those technologies usually lower. (Naturally, there’s an exception for the allied-health majors, in which we have to adopt the technologies that hospitals have, just because hospitals have.) The trend towards adjuncts hasn’t hit health care in quite the same way, though I’m told that nurses now shoulder some of the tasks that doctors used to.

Both industries suffer by comparison to most of the private sector, which our political culture now regards as normative. A car company will adopt those technologies that promise to save (or make) money; everything else, it ignores. Neither a hospital nor a college has that luxury. When our prices rise faster than the car company’s, then, politicians make great hay attacking the out-of-touch elites (doctors and professors) whose presumed arrogance is (to them) the only possible explanation for comparatively rapid inflation. (Not for nothing, but car company executives’ salaries make professors’ salaries look simply pitiful.)

In both cases, what are truly and properly understood as public goods (health care, education) have been miscast as private goods, with predictable consequences. Whether I use the MRI machine at the local hospital or not, I benefit from its presence. I benefit from discoveries made possible by the treatments given to other people. In the same way, the economic benefits of an educated workforce benefit me, even when the education goes to other people.

By dropping the category of ‘public goods’ from our political conversation and elevating the standards of mass retail as the basis for judgment, we have fundamentally misunderstood and mismanaged two of the most important pillars of our society.

The United States has, by far, the most expensive health care system in the world, but its results are nowhere near the top when measured by such standards as life expectancy, infant mortality, or percentage of population covered. We’re spending the most, but getting mediocre performance. We’re screwing it up.

In higher education, the picture is both murkier and more positive. On the high end of the prestige hierarchy, we still draw some of the best minds from around the world to the U.S. for undergraduate and graduate education (although that has slowed somewhat with the Bush administration’s clampdown on immigration, post-9/11. Richard Florida, among others, has called attention to the Bush brain drain, with the best minds from other countries eschewing the U.S. for study in Australia, Canada, or India. We don’t feel it now, but when the next Microsoft emerges in Bangalore or Canberra, instead of Seattle, we’ll be in trouble.)

On the low end, our uniquely-American community college system has drawn international interest for its ability to bring the benefits of higher education to the middle and working classes at reasonable cost. For all its flaws, it’s a wonderful system, founded on a clear understanding that an educated workforce is, in fact, a public good.

What to do? I haven’t finished the speech yet...