When Duty Calls: The Value of Voting, Beyond Politics

Jean-Francois Martin

In recent years psychologists and neuroscientists have tried to get a handle on how people make voting decisions.

The New York Times, November 4, 2008, by Benedict Carey — For those who love the civic cheer and lukewarm coffee of their local polling place, an absentee ballot has all the appeal of a tax form. The paperwork, the miniature type, the search (in some states) for a notary public: it’s a tedium bath, and Pam Fleischaker, a lifelong Democrat from Oklahoma City, had every reason to take a pass this year.

Ms. Fleischaker, 62, was in New York recovering from a heart transplant, for one. And in her home state, the Democratic candidate, Senator Barack Obama, was polling hopelessly behind his opponent, Senator John McCain. She mailed in her absentee packet anyway, and hounded her two children, also in New York, to do the same.

“That one vote isn’t going to be decisive makes no difference to me,” Ms. Fleischaker said in a telephone interview last week. “Your vote is your voice, and there’s more power in it than in most of the things we do. It’s a lost pleasure, the feeling of that power.”

In recent years psychologists and neuroscientists have tried to get a handle on how people make voting decisions. They have taken brain scans, to see how certain messages or images activate emotion centers. They have spun out theories of racial bias, based on people’s split-second reactions to white and black faces. They have dressed up partisan political stereotypes in scientific jargon, describing conservatives as “inordinately fearful and craving order,” and liberals as “open-minded and tolerant.”

None of which has helped predict people’s behavior in elections any more than a half-decent phone survey. The problem is not only sketchy science, some experts say; it’s that researchers don’t agree on the answer to a more fundamental question: Why do people vote at all?

“There’s a longstanding literature looking at why any rational person would vote, when the chances of actually influencing an election are about the same as getting hit by lightning,” said John Londregan, a professor of politics and international affairs at Princeton. “In most theoretical models, it’s hard to get a predicted turnout above one. That is, one voter.”

Yet new models have done better, predicting elections with turnouts closer to the nation’s average of about 50 percent of eligible voters. They have also revealed some of the basic motives underlying both personal and group decisions about when to vote and why.

Casting a ballot clearly provides a value far higher than its political impact. The benefit may include side payments — say, the barbecues and camaraderie of a campaign, or the tiny possibility that a single vote may be decisive.

But recent research suggests that it has more to do with civic duty and the maintenance of moral self-image. In a series of experiments, researchers from Northwestern University and the University of California, Berkeley, have had study participants play a simple election game involving monetary rewards. A group of designated voters cast their vote for Choice A, an equal distribution of money among voters and nonvoters in the study; or B, a payout to be split only among the designated voters — a smaller group, so a higher amount. It cost money to vote, and participants could abstain at no cost.

The study authors, led by Sean Gailmard at Berkeley, called Choice A “ethical” and Choice B “selfish.” They found that ethical voting ran highest, at about 20 percent, when individual votes were least likely to affect the outcome. Selfish voting ran highest, also about 20 percent, when individuals’ choices were most likely to change the outcome.

This finding could explain why people might vote against a local tax increase but for a Congressional candidate who was likely to raise their income taxes: their vote carries far less value in a national race than in a local one.

This study and others also imply that there is a core of voters who not only turn out at the polls but also cast their ballot for the candidate or proposal they believe represents the larger good. This makes sense to those who study the evolution of group behavior. Small communities often have a scattering of people who stand up and do the right thing; their compensation is the private knowledge that they are willing to pay some cost to do what they believe is right, even if that price amounts to standing out in the cold for 15 minutes waiting to pull a lever.

“It may be a form of identity construction for individuals,” Dr. Gailmard wrote in an e-mail message. “Or it could be a duty to do the right thing, or a social norm.”

Ms. Fleischaker, the absentee Oklahoma voter, put it this way: “Who are we to ask others to do things for this country, small or very large, like fighting in a war, if we ourselves are not going to take the trouble to vote?”

The military analogy is not overdrawn, Dr. Londregan says. In a 2006 paper, “Voting as a Credible Threat,” he and Andrea Vindigni of Princeton argue from historical and sociological evidence that at times of deep division, elections function as an X-ray into the strength of the opposition, the number of people willing to bear a cost to have their way. In the extreme, election returns prompt factions on the brink of civil war to reassess their chances and negotiate — making communities, small and large, far more stable and adaptive.

“We started to see that elections function as a kind of SAT score to show what kind of guerrilla you’d be,” Dr. Londregan said. “They’re a way to see how many people would actually fight to oppose a policy — and how much is just bravado.”

Dutiful voters know all this, at some level, no matter how they define the larger good. They think more broadly about what others of their stripe will do, spending more effort if they feel their home team will be underrepresented, political scientists have found.

By taking into account such calculations, as well as ethical voting, the costs of casting a ballot and other parameters, Timothy Feddersen and Alvaro Sandroni of Northwestern University — Dr. Gailmard’s co-authors on the ethical voting research — have designed a model that accurately predicted turnout in several local Texas elections.

“The model predicts that in states where the election is close, turnout will be high among all groups,” Dr. Feddersen said, adding that in the toss-up states, “partisans are less likely to vote when they are in the majority and more likely to vote when they are in the minority,” or expect to lose.

In short, expect the race in states like New York and Oklahoma to be closer than polls show, not because of hidden racism or “inordinate fear” but because many people find it satisfying to stand up and be counted — even if they’re doing the counting for themselves.

FORBES.COM, by David M. Cutler and J. Bradford DeLong — Every other North Atlantic country spends less than half what we spend on medicine. Every other North Atlantic country is healthier than America.

This extraordinary gap–between how much we spend on health care and what we get for it–is not because our doctors, nurses and pharmacists are unskilled or undedicated. On the contrary, they are the best in the world. But they are embedded in a poorly designed system that gives us low value for our money.

Taking the long view, the inefficiency of our health system is the biggest threat to economic growth over the next two decades–bigger, even, than the current financial crisis. The doubling of health insurance premiums since 2000 has forced employers to choose between cutting wages, cutting benefits and hiring fewer workers. The result is lost profits and lost wages, in addition to pointless risk, insecurity and a flood of personal bankruptcies. Without serious changes, this problem will only get worse.

Democratic presidential nominee Barack Obama wants to address the health care crisis head-on. Like Franklin Roosevelt, who faced equally large challenges, Obama will try many strategies and be guided by results, not predetermined ideological conviction. The strategies he proposes fall into four general areas.

One element of reform is information: Doctors, patients and administrators simply do not know enough about which treatments work and which are ineffective or harmful. An estimated one-third of medical costs go toward care with no value. Obama proposes to jump-start the long-overdue information revolution in health care with $50 billion to computerize the medical system and spread the word about best practice.

A second element is to fix perverse incentives in medical care. Doctors and hospitals today are paid for performing procedures, not for helping patients. Insurers make money by dumping sick patients, not by keeping people healthy. Obama proposes to base Medicare and Medicaid reimbursements on patient outcomes in a coordinated effort to drive the entire payment system toward paying for improved health rather than just more care.

A third element is to help the small players–individuals and small firms–get the same deals as large buyers. Obama proposes purchasing pools where individuals and small firms get the same low rates as large firms and sick people get coverage the same way as the healthy. Our current system of excluding the sick from coverage does not make their costs disappear but rather assume other, less efficient guises.

A fourth element is prevention. In today’s health-care market, less than one dollar in 25 goes for prevention–despite the fact that three-quarters of medical care is for conditions that could be prevented. Guaranteeing access to preventive services will improve health and, in many cases, save money.

As the reforms take hold, costs will drop. As costs drop, insurance will become more affordable. Millions previously priced out of the market will be able to buy insurance. Add on tax credits for those still unable to afford coverage and for small businesses, and everyone will have access to affordable, portable insurance.

By contrast, Republican presidential nominee John McCain believes that the central problem in health care is that people have too much insurance and, because of it, consume too much medical care. McCain seeks to reform the health care system by taxing and punishing businesses that offer employer-sponsored insurance. Once they are forced to drop coverage, he holds, their workers will find themselves in the non-group health insurance market, where they will buy less generous plans and go to the doctor less often. Modest tax credits would help some, but nowhere near all, of the uninsured afford coverage.

We are skeptical of the value of McCain’s plan for three reasons. First, the tax increase McCain proposes and the resulting dislocations it creates are the last thing American business needs now, when it’s in the midst of a severe economic crisis. Second, the non-group market is nowhere near as rosy as McCain makes it out to be. People who buy insurance in that market now are risk rated, see their pre-existing conditions excluded from coverage or priced higher and are never secure in their coverage. The McCain plan would amplify, not fix, these problems.

Third, the McCain health plan has a huge financing hole–between $1 and $2 trillion over the next decade. Only the most draconian Medicare and Medicaid cuts would make the plan work. But such cuts would be devastating for the very providers that are needed to make health reform work.

It is clear to us that Barack Obama’s health care reform plan is much better for the country, and much more likely to be successful, than John McCain’s.

David M. Cutler, the author of Your Money Or Your Life: Strong Medicine for America’s Health Care System, is the Otto Eckstein professor of applied economics at Harvard’s department of economics and Kennedy School of Government. He is also an adviser on health care to Barack Obama. J. Bradford DeLong, who blogs at http://delong.typepad.com/sdj/, is a professor of economics at U.C. Berkeley. Both authors are research associates at the National Bureau of Economic Research.

Forbes.com, by Robert Langreth — Johnson & Johnson earns billions selling high-tech drugs, medical devices, diagnostic tests to people who are already sick. Now it hopes to create a vast new market by selling services to healthy folks to help keep them from ever needing such products.

The health care giant yesterday acquired HealthMedia, a small Michigan company that develops sophisticated Web-coaching tools to help employees lose weight, quit smoking or manage stress. J&J (nyse: JNJ – news – people ) has been a client of the firm and has been impressed with the results it has seen in its own workers. It hopes to expand the offering much more broadly and sell it to big companies and governments across the world. Ultimately J&J could sell wellness services directly to consumers as well.

The move is a path-breaking step as J&J seeks to pinpoint the next big health care growth opportunity. It comes as sales growth has ground to a halt in its drug business, thanks to safety problems and patent expirations that are bedeviling the entire pharmaceutical sector.

Wellness could be that next big thing, says J&J vice president Nicholas Valeriani, who was tapped a year ago to map out new business opportunities that go beyond J&J’s current focus on drugs, devices and consumer products.

Today “the health care system is a disease-care system and consumers aren’t concerned about [their health] until they are sick,” says Valeriani. “A lot is pointing to the fact that the time is right for wellness and prevention.”

One big factor is surging health care costs. “Health care systems cannot continue to afford the escalating costs we are seeing,” he says, arguing that better prevention programs could save employers and governments large amounts of money.

Many health care researchers lament the current medical system’s focus on treating disease when many, including obesity, diabetes and cardiovascular disease can be staved off through diet, exercise and other preventative measures. Big Western countries only spend about 3% of their health care budgets on prevention and public awareness programs, according to the Organization for Economic Cooperation and Development.

One problem is that counseling and behavior change is difficult and time consuming. It is easier for doctors just to prescribe a pill and send someone home, rather than teach them lifestyle changes that could produce the same benefit.

J&J hopes sophisticated Web-based systems could be one answer. Using the latest evidence-based medicine and proprietary algorithms, Web coaching systems can scan in detailed patient data and design a customized program for that particular employee. Currently, various Web-based wellness offerings are scattered about at various small companies, says Valeriani. “We are hoping to provide an integrated one-stop [shopping] from employers” hoping to deal with a multitude of conditions.

Valeriani was appointed to head J&J’s office of strategy and growth nearly a year ago. So far, he has identified three potential future growth areas, including health care information technology, health care services and wellness/prevention. While wellness is the first focus, he doesn’t rule out also expanding into the other areas.

In an interview before the HealthMedia deal, J&J Chief Executive William Weldon said that he doesn’t expect immediate financial benefit from the new areas but is thinking for the long haul. “We don’t expect we will see huge returns coming from that for a period of time,” Weldon said. Every few decades J&J has entered a totally new business, he says. The company moved into prescription drugs by buying the Belgian drug firm Janssen Pharmaceutica in 1961. “Now we are seeing what is the next thing.”


We can solve the spending crisis if we can unshackle real innovations in the medical industry.

Clayton M. Christensen, Jerome H. Grossman and Jason Hwang
Forbes Magazine dated November 17, 2008 — Normally it’s good news when an industry increases its share of the American wallet. It usually means that the industry is producing goods and services that people value. Health care has been a big share gainer. In 1970 the U.S. spent 7 cents of every gross domestic product dollar on health care. Now it’s 16 cents. Good news, right? It must mean that people value good health and they’re better off investing in it than in other diversions.

But this is not good news. It’s terrifying, and we’ve heard many times during this election season what’s wrong with this picture. An increasing proportion of Americans cannot afford or access adequate care. Within 20 years Medicare outlays, left unchecked, will crowd out all other federal budget items except defense. Employee-benefit spending makes U.S. companies uncompetitive in world markets. Almost any city or town would be bankrupt if it put on its balance sheet the commitment to provide health care for retired employees.

The runaway factor here is the fee-for-service reimbursement system that predominates in private and public insurance plans. French economist Jean-Baptiste Say predicted 200 years ago what would go wrong: When caregivers make more money by providing more care, supply creates its own demand. Half of all care consumed seems to be driven by physician and hospital supply, not patient need or demand.

If health care is a terminal illness for America’s governments and businesses, the rest of the world isn’t far behind. Nationalized health systems such as those in Canada and Great Britain seem good at making everyday care conveniently accessible, but budget limitations continue to result in long lines for specialty services and technologically advanced care. They, too, are turning to private insurance, which offers their citizens greater choice.

There’s broad consensus that the U.S. needs a system that is competitive, responsive to consumers and equipped with clear metrics of value per dollar being spent. But very few forces agitating for reform have the scope and power to reconfigure the elements of the system. Almost every day somewhere in the U.S. a group of reformers convenes a conference. We’ve attended many of these. Nearly without exception the participants talk past each other. This one focuses on the uninsured poor; that one on drug coverage for the elderly; this one on overuse of expensive diagnostic technology. They talk past one another because they don’t share a common language or a common understanding of the root causes of these problems.

In our book, The Innovator’s Prescription, we attempt to provide a map to those seeking innovation and reform. Instead of trying to figure out how to pay for the cost of care, we try to work on the other half of the equation: How to innovate to reduce costs and improve the quality and accessibility of care. We don’t ask how we can afford health care. We show how to make it affordable and improve quality.

The problems facing the health care system are not unique. Nearly every industry at its outset produces goods and services that are so complicated and expensive that only rich people can afford them. Only the wealthy had access to telephones, photography, air travel and automobiles in their first decades. Main-frame computers were owned only by the largest corporations and universities and were tended to by trained experts.

At some point disruptive innovation transformed all these industries, making their products and services affordable and accessible, so that people with less training could competently provide them. Disruptive innovation requires three things: a change in technology that simplifies a complicated technical problem, a business model that can take those simplified solutions to the market at low cost and a supporting cast of suppliers and distributors to reinforce the disruptor in the middle.

Disruptions that combine these three factors have had some success in health care. In diagnostics, companies such as Inverness, Quidel and Abaxis have lowered costs and increased convenience by inventing compact machines that can be used in doctors’ offices and do the blood work that used to be sent out to central laboratories. In less than a decade General Electric’s health care division and Sonosite have together created a $1 billion market for handheld and portable ultrasound equipment. The technology exists for lower-cost home dialysis for kidney patients, but the companies selling dialysis machines and services are incented under reimbursement schedules to keep patients at inpatient renal centers. Companies like MinuteClinic, which employ nurse-practitioners in pharmacy chains, threaten to disrupt physicians’ practices with convenient lower-cost care for consumers.

Some cost-saving disruptions are already well entrenched. Home blood-sugar monitors have replaced tests administered in doctors’ offices. Patients use the Web to acquire education; a decade ago that would have consumed costly face time with doctors.

Other disruptive innovations are on the way. Precision diagnostics, which uses genetic and cellular targeting to decide which drugs are best suited for individual patients, is dragging disease care out of the realm of guesswork. Electronic health record systems have been launched by Allscripts and GE. Newer innovators like Google, Revolution Health and Docvia are enabling patients anywhere in the world to manage their health using the Internet or their mobile phones for less than ten cents per encounter.

But for these forces to work we have to remove a host of factors that trap the delivery of care in obsolete and costly business models. Fee-for-service reimbursement needs to be replaced by high-deductible insurance and health savings accounts. Employers need to play a much more active role in directing employee care, negotiating with providers for discounts and access. This is how they can facilitate disruption.

Adam Smith’s invisible hand is nowhere to be found in health care reform. We need what business historian Alfred Chandler called the “visible hand of managerial capitalism,” the deliberate involvement of an integrated, fixed-fee provider that covers the patient from start to finish and profits from patient wellness. Such a provider can even disrupt its own hospitals and specialist physicians by using lower-cost caregivers and venues of care. The few providers that fit this profile—Kaiser Permanente in California, Intermountain Healthcare in Utah, Geisinger Health in Pennsylvania—should expand their geographic scope to a regional or national scale and encourage providers that are not now integrated to become so.

The general hospital is not viable, and most would collapse tomorrow in the absence of subsidies, restraints on competition and philanthropic life support. Trying to diagnose and treat any disorder that anyone might bring through their doors has forced them to separate their individual specialist physicians and their pieces of equipment (i.e., radiology and surgery suites). This is good for shuffling patients from one department to the next in a flexible way, but it means that hospitals lack the tight integration that allows them to address adequately the different needs of individual patients. This complexity drives up their overhead and has in many cases led to inconsistent quality and safety. This is why many patients now opt to get their knees, spines and cancer treated in specialty hospitals designed around a narrower set of procedures. Hospitals need to disrupt themselves, or be disrupted by others, to reduce cost and improve quality.

Primary care physicians need to be dissected as well, handing off routine care such as treating earaches and performing camp physicals to retail clinics and assigning the care of chronically ill patients to disease management networks. These physicians can focus on getting back some of the business they’ve been losing to specialists by resuming more hands-on work of intuitive medicine.

We have seen a pervasive pattern in every industry that has been transformed through disruption, and health care is no exception. The energies, talent and resources of the leading organizations are concentrated on improving their best products, which are sold to address the most demanding applications. That’s where the high-profit customers are.

When disruptive enablers emerge, the leaders disparage and discourage them because of their simplicity and accessibility. But the disruptors eventually gain a foothold, progressively displacing the old, high-cost approach. It’s a hoary example but worth repeating: Toyota’s launch vehicle was a Corona, not a Lexus.

Doctors, hospitals, regulators and policy-makers need to convert to this religion because it isn’t myth: It is true. The fact that disruptive enablers can address only the simplest of problems at the outset is indeed a gospel of good news. It frees physicians and hospitals to focus their energies on what they do best—tackling complex medical problems and moving more problems along the spectrum from intuitive medicine toward precision treatment.

Yet industry leaders have repeatedly lobbied for legislation and regulation that block disruptive approaches from being used anywhere until they are certifiably good enough to be used everywhere. This traps the industry where it began, in the world of ever higher costs. The health care industry needs to be disrupted. We hope that our book speeds the process.

The Real Dismal Science
The Home Cure

Clayton M. Christensen is a professor of business administration at Harvard Business School. Jason Hwang, M.D. is senior strategist for the health care practice at Innosight LLC. Jerome H. Grossman, M.D. was a nationally recognized health care policy expert and former hospital CEO. This excerpt was adapted from their forthcoming book, The Innovator’s Prescription: A Disruptive Solution for Health Care (McGraw-Hill, 2009). Go to forbes.com/leadership for more of Christensen’s thoughts on innovation.