Reforming the Heathcare “Debate”: Function Junction

Alright, well, we discussed . . ok, I dictated. . . the problems with the healthcare system and no one seemed to complain; so, I will go on to step 2, Solutions. . .

Nope!!!  Not yet.  (Didn’t I say I was going to suck all the life out of this debate?)  While we know at a high level what is probably bothering everyone about the Healthcare System, we don’t really have enough of an understanding of the System to actually start thinking about how to fix it.  To go back to our broken car analogy, we’ve determined its problems (fuel efficiency is not what it is supposed to be; its acceleration is lacking; and its performance is continually degrading.), but we did this by comparing it to other similar vehicles.  We can’t rationally decide how to fix it (or if we should just replace it), because we haven’t really looked under the hood to see what kind of engine it has.

Part of the reason we need a better understanding of the system is due to the nature of the brain.  I keep using the car example, because cars are easier to think about than a massive transactional system.  Cars are physical objects, and the human brain does really well with physical objects.  All the way back in the womb, each one of us started unconsciously building a library of physical laws in our brains.  Through our earliest years, we subconsciously and consciously conducted science experiments to refine this library (learning to roll, repeated interactions with toys, dropping spoons).  So now, if you read “car” you probably (and immediately) think of a four-wheeled platform with a gas pedal, a brake pedal, a steering wheel and an engine (again, “engine” and all those other components trigger their own images).  However, if you read “Social Security System” I will bet that you don’t quite get such an image.  You might think of your Social Security Card or Number; you might think of income taxes or some personal view of the politics involving that System; but you don’t actually think of an image which brings all of those parts together (not as concrete of an image as you do with “car” or “engine”).  This failure isn’t because such an image doesn’t exist, or that the system is really that complex, but because our brains don’t have such a well established and detailed library of transactional systems and the natural laws which make them work.   (Think of the first time you really understood what a government was--not just the names of the founding fathers or state capitals.  At that age you could already imagine a basic car (and could probably draw one—talent dependent).) 

This limitation is important, because we have to understand that a transactional system like Healthcare can—and I say should—be treated like a physical thing.  I say “should” because dealing with these concrete terms gives us major advantages over some philosophical concept, which is all we will really have otherwise.   Once we define it in somewhat concrete terms, then we have a better chance of coming up with more reasonable and quantifiable solutions.  The more measurable the definition the more likely we can be certain of the solution.  We have to first accept the idea that the System actually does have definition like a car though it may be difficult for us to picture.  One way to get that picture is to think about its most general functions.  For example, a car has several obvious functions:

- It can move itself forwards or backwards.
- It can stop its motion.
- It can be turned while moving forwards or backwards.
- It allows one person, the driver, who rides on it to direct and coordinate these functions.
- It moves based on an energy supply that it carries with it.
- It has the capacity to carry more than the driver.

You’ll notice that this could fit the definition of a car, a moped, a motorcycle, or a bicycle-built-for-two (if you consider the people to also be energy supplies).  “Car” is one solution to this set of functions.  If we got more specific about these functions --“It can move forwards at 55 mph”—it can narrow down that list to “car.”  Because of the challenge of picturing the Healthcare System, we should stay at this less detailed level of description.  The Healthcare System will take a bit more work to think up, but it’s the only way to get a realistic and useful set of possible solutions. 

Let’s start this by mastering the obvious.  The Healthcare System revolves around human health.  Sure, this sounds pretty clear, but it’s a philosophical rabbit hole.  What is “health”?  How do we measure “health”?  We’re going to have to follow the white rabbit to get to the answer (a la Alice in Wonderland or Matrix—I’m sure Matrix fans would prefer “take the red pill” however, the white rabbit reference is valid, check it!).  The first stop in the hole is that sign that says “Health is the state of being healthy”, which doesn’t seem to tell us much of anything unless you go deeper and is pretty much the dictionary definition.  Where else should we go for this definition, the highly technical journals or the ads for Abrocker or Vitameatavegamin?  I think the more reasonable path is actually to think about our own experiences with being healthy. 

First, we’ve drawn the boundary of our Healthcare System such that it leaves out food production.  This implies that we can’t actually talk about healthy diets, at least in this part of the discussion.  This sort of limits us to thinking about what could possibly send us past the boundary we’ve defined.  If you’re a male between 18 and 40, you probably aren’t going to be familiar with this term, but the standard point-of-entry into the system is called your “annual check-up.”  This exam is the standard point of entry into the healthcare system.  It normally involves the following, according to WebMD:

-Blood Pressure
-Heart Exam
-Lung Exam
-Head and Neck Exam
-Abdominal Exam
-Neurological Exam
-Dermatological Exam
-Extremities Exam
-“Sex Specific Exams”
-Lab Tests: Blood Count, Chemistry Panel, Urinalysis

Depending on what they find here you may go further into the system or stay out.  Notice that most of these tests aren’t actually looking to tell how well you are, they are actually trying to find something wrong with you: signs of disease, cancer, disorders and other anomalies.  Consider what can’t get caught in a doctor’s office, which might send us to the ER—none of those things would make you say “I am so incredibly healthy!”  “Healthy” for the System seems more about what takes us away from some “normal” physical state than what could make us better than normal.  If we think about what brings us into the system, we first have to think that it is about identifying problems with our health and then trying to find some resolution to those problems.  Finding some resolution is kind of a target and not necessarily a “shall do” because there might not be resolutions to some particular problems.  For this reason, let’s state our first requirement as:

The Healthcare System should detect health related problems of individuals and restore those individuals to as full health as possible with all available knowledge and technology.

I think this requirement is rather complete, but it really only talks to one aspect of the system.  The other major component of the healthcare system is the business end, literally.  Let’s not get into the solution side of this (federal program vs. individual funding) but talk to more of the obvious.  More specifically, let’s talk about all the people in the system that should to get paid (leaving out how they get paid).  Obviously, everyone in the system who provides a service should get paid.  However, let’s get a little more specific.  Everyone who participates in the function we previously described should get paid towards their contribution to that diagnosis and restoration.  We can look at this as something more concrete, like a construction contractor.  The contractor gets paid for doing to the work and that money gets split up according to the job: some goes to the guys who did the work (usually at a predefined rate agreed to before the job started and normally based on hours), some towards the rental or purchase of certain tools, some goes towards materials used on the job, some goes towards future growth of the firm, etc.  The workers come in different price ranges dependent on their availability and any special skills they possess—the rarer, the higher the bill.  Why should we consider the pay scheme to repair a house, a car or a refrigerator to be any different than that of a person?  Yes, there are more specialties and equipment involved, but no matter how you combine them, they don’t really change this fundamental structure.  Does hospitalization really change the structure of a Hotel payment structure combined with a repair facility payment scheme?  The requirement for payment seems to be this:

The Healthcare System should pay those involved in the actions relative to providing goods and services as the real cost of labor and material allowing normal growth (as with any other business).

There is another side to this requirement, pricing.  Not only should people be compensated for their actions, but they should also fairly reflect the pricing of their goods and services.  I love to use pricegrabber.com because I can quickly compare the prices of things I’m interested in buying at a bunch of stores to find the best price for those items.  It also gives ratings for those stores so you also know the likelihood of a good delivery, and how they handle any issues with the thing you bought.  Pricegrabber is really only making the job of comparative shopping easier, but it is something we do (or should do) with any purchase.  Comparative shopping is simply the market at work.  The ability to compare prices and goods between different stores keeps those prices in check.  The more competition that exists for particular products, the closer to the real price of the good or service one is likely to get.  This pricing competition works for contractors and mechanics as it does for product retailers.  Why shouldn’t it also be the basis of Healthcare pricing?  The only unusual case which the users of the Healthcare System must deal with is the Emergency Room.  One doesn’t normally have the time to compare prices for ER services which may cause price gouging.  However, we can make one general requirement that covers both of these:

The Healthcare System shall provide a means provide fair pricing for services and products rendered.

The three preceding requirements are pretty cut and dry for a normal business (provide a service, pay people for providing that service, price your service reasonably), but we have one requirement that is far outside the norm for a typical business—access.  Normally, businesses only provide access based on the ability of the customer to pay for that service.  For instance, a mechanic is not going to do a job for free; they might not even diagnose the problem for free, but for Healthcare, we must mandate access to everyone.  Let’s actually keep this requirement as vague as it sounds:

The Healthcare System shall provide full access to all available knowledge and technology to all potential users.

If we accept this as a “must have,” then we can consider all of the options towards meeting that requirement in the next phase.  This requirement also does not exclude people who can pay or pay part of their care and will lead towards some novel solutions when we consider these requirements together.  It also seems to make us start thinking about those who might abuse this access.  What if people pretend they can’t pay when they can?  Who actually will pay?  When you think of large organizations, you can probably conceive of a million ways that system can be cheated.  For our problem, I believe we should consider this cheater problem beyond just this requirement.  It’s too vague to say “make sure people don’t cheat,” but something should be included about cheater prevention.  Let me propose (again, I really mean “dictate”) the following requirement:

The Healthcare System shall have a means to regulate each functional requirement such that it automatically prevents abuse.

This requirement essentially means that for every idea we come up with for a requirement there should also be an idea for how to keep that concept from being abused. 

So, that’s it, and by “it” I mean this part of “it” not actually all of “it.”  Next time I’ll actually talk about potential solutions, and by the pace of the Healthcare “debate” I’m pretty sure I’ll have time to get into it.

Reforming the Healthcare “Debate”: Admitting We have a Problem

What can I really say at this point in the healthcare debate besides “Shut up!” It’s the same reaction I have in some meetings at work, except I keep it to myself (unless, I’m saying out loud and no one is telling me because they all think I have turrets). If you think you attend too many worthless meetings at work, you’re probably right. It’s easy for meetings to go haywire, especially the more people you have in them. More often than not, the main problem is no one will have set a meeting objective up front or provided any path towards resolution of the issue—a key point here being, there should be an issue. The entire point of a meeting should be to resolve something which could not have been done without getting everyone in the same room. So, if you have everyone in the room, you should probably have a plan to get something out of it.

Similarly, people’s time has been wasted on this Healthcare Reform “debate” in the last few months. Like a haywire meeting, there is no structure or direction for a constructive resolution. Much like most political wrangling of the past couple of decades, we haven’t started with the basic agreement on the current accepted definition of the “Healthcare System” nor is there an accepted definition of the problem of that system. Can we at least agree to that? Without this foundation we cannot possibly agree to a solution, because we don’t know what we are trying to fix.

Let’s think of the Healthcare debate as a more concrete problem. Suppose your car started acting funny (its fuel efficiency dropped recently; it’s making funny noises, and it doesn’t respond to you as quickly as it used to), and you take it to a mechanic. After you drive it into the shop, the lead mechanic brings in everyone into the bay and has you start it up. Everyone is watching and listening to your car from the back of the bay—its hood closed and no one looking at the dash—he has you shut it off and asked for solutions from everyone there. Everyone chips in an idea and they establish a few camps: replace the engine, fix the NOX system, and do nothing.

You probably think this is a ridiculous scenario. You may not run a mechanic shop, but you know there are some steps to go through before jumping to solutions. First, understand the vehicle--we can’t normally understand the peculiarities of a Pontiac by reading the repair manual for a Porsche. Second, try to isolate the problem, normally by gathering as much data about that problem as possible. Listen to it run, yes, but also open the hood, look at the lights on the dash, check all the fluids, hook up a diagnostic computer, etc. One can’t be confident in a fix unless the problem is given some context which may also include what is working correctly. This research and investigation, a contextual foundation, is not part of this Healthcare Debate, and if we admit first that there is a problem, then we have to build the context of that problem. Our President and Congress are deadlocking in a debate of solutions without establishing the foundation of the problem and how their solutions resolve these points.

All sides are taking advantage of this ambiguity by playing on emotions, misrepresentation and tangents. What’s worse is that those who should be getting the debate on track are taking the bait and falling prey to these emotional misdirections. As I see it, the problem with the Healthcare System is a technical issue, just like the problem with your car. The system has definition: it has things it must do; it has particular ways it responds to individuals. Just because it is made of people and not metal, doesn’t mean it can’t be handled like a broken car. Emotions shouldn’t come into play when you’re trying to fix your car or when you’re trying to fix the Healthcare System. (A good rule of thumb for almost all political “debates” is “if you’re getting emotional, you’re getting played.” Emotional appeal is the weapon of choice for politician and those trying to manipulate the government for as long as there have been governments. People are emotional and some of us tend to use political philosophies as part of our identities, just as we do with our favorite sports team, or band. Unfortunately, in politics this makes us quite a bit more susceptible to manipulation and personal injury. Normally, the best answers are approached in a cold logical fashion (Live long and prosper)) Addressing this as a technical problem also means that we’ll suck the life out of the debate, but boring is good in this case.

To begin this emotional drain let’s define the Healthcare System as it is now. Now this has nothing to do with the future form of the system (a cuban/commie/barcoding system, an unregulated/free market/credit score-based system, or a witchdoctoring/juju wearing/tattoo-based system). A “system” just means we have some boundary to the thing. When we talk about the problems of the “Heathcare System” we probably mean doctors, pharmaceuticals, hospitals, health insurance, patients and the relationships between them. We won’t talk about agriculture, police departments, the military or clown colleges (unless they provide some related examples).

As part of this definition we need to also define the current healthcare system’s function. Can we say, “Provide medical care to all individuals when their health is at risk”?

This function seems kind of odd, and you may debate the “all individuals” statement, but as the system is defined right now, that is what it does. Since 1986, the Federal Emergency Medical Treatment and Active Labor Act has required that all Emergency Rooms accept ALL individuals no matter their ability to pay for those services. If you disagree with this, ask yourself what you would want an ER to do with you if you were mugged and beaten; wait until they could confirm you could pay? It might be a while, particularly if you were unconscious with no identification, and in that state would you really want them to wait to see if you were bleeding in your brain? More than likely, you would want the service immediately. The problem most people have with “ER for all” is the payment aspect of these services. The act did not provide for any type of funding for ER’s to provide this mandate. As a result of this act, hospitals just have to “work it out”, and they thought it was wise to make the insured patients pay for it. This payment aspects falls into the problem category of the system.

Let’s take the second step and try to define the problems with this system at a high level. The more measurably we can define this problem(s) the better chance we will have at finding a solution that we can prove will work. The numbers are most available for one of the most common complaints about the System. The following chart comes from data available at the Organization for Economic Cooperation and Development. The following data compares the capabilities of the healthcare systems with the cost of those systems per capita. In this table I have included the U.S. against the most efficient industrialized nation, South Korea, and the best “scoring” nation, Japan. (I considered the score to include the number of “Deaths per 1000 Live Births” and the “Total Life Expectancy at Birth.” My rationale for these parameters was as follows: if the “Death per Live Births” for these other nations were higher than the US then they would loose more at the “front end” of their system, just as if their “Life Expectancy” would cover their “back end.”) Both nations beat out the US in both of these categories while costing about a third to a sixth of what it does per each US citizen. If you care to cruise the OECD, you will also note that almost all industrialized nations are far closer to S. Korea and Japan in their numbers than to the US.

This means that in general, the US system costs us more while giving us less. When compared to most industrialized nations it costs us far more.

Problem 1: General System Inefficiency. Costs are High and Return Value is Low

The second problem we feel more personally than any other—the growth in cost of the healthcare system. We see this in the cost of our medications, deductibles, and the growing number of things insurance refuses to cover. We can see this through data from the Centers for Medicare & Medicare Services site. The chart, below, is the per person cost of healthcare from 1960 to 2007. It looks like the elbow of an exponential curve, but we need to look at this data more realistically by using the growth in per capita income.

If we chart the cost of healthcare as a percentage of personal income (from the Bureau of Labor Statistics), we can see that this is not as harsh of a runaway—not exponential at least, but we can see how much healthcare is biting into our personal incomes, a 194% increase since 1960. We’d all probably like to be paying 7% as opposed to 22% of our incomes to healthcare. (We should also recognize that this per capita isn’t really representative since there is a more complex distribution of who actually ends up paying versus receives care just as there is a more complex distribution of income. For what is a rather long blog post already, we’ll stick with these averaging assumptions—a “what would it cost if we shared it all evenly.”)

Problem 2: The growth in the personal cost of healthcare as a % of personal income.

Speaking of uneven distributions, we find another problem regarding the means of access to the Health Care System. As of 2008, 15.4% of the United States citizens (46.3 million) were uninsured. As we stated earlier, this doesn’t mean that they can’t get into the Health Care System—they can get into ER’s—they just can’t get into the places through which Health Insurance lets them in—a normal doctor’s office, to the pharmacists counter, etc. This access limitation normally means that instead of being able to see a doctor about some ailment that could be taken care of earlier, they have to wait until it is debilitating enough to send them to the ER. This of course means that the ER’s get backed up with issues that could have been handled earlier and cheaper elsewhere.

This access limit means that ER’s get overstrained because of their government mandate, health insurance providers have to negotiate the fair price of payment because they know they are being used to pay for the uninsured visits, and the insured patients are carrying the brunt of the cost of the system. In the end this means that hospital charges go up, deductibles go up, the percent of personal income that goes to healthcare goes up, and the number of people who can’t afford health insurance goes up which causes this feedback loop to feed itself to oblivion. Health Insurance providers don’t just respond to this loop by increasing deductibles, but also by pairing their clientele back to lower risk individuals. This means they can charge higher deductibles but be less likely to pay out, strengthening their bottom line, but at the same time increasing the pool of uninsured people who will eventually cause prices to go up.

This problem does not translate directly into “lack of access to health insurance” though we could go there. To be more general, it is fair to say that the problem is that there is a lack of access to all aspects of healthcare. Even the insured are limited in their access to the Healthcare System. As a function of their insurance provider, insured people can’t just go to any doctor or hospital. They are limited in their choice. This not only causes challenges to patients, but it means that any free-market competition with hospitals and doctors is based on their appeasement of insurance providers not patients.

This problem is most correctly put as “the limitations of patient access to all aspects of the healthcare system.” Meaning something to the effect of, few individuals can get to the services they need even if they are the best thing for them and the system as a whole.

Problem 3: The limitations of patient access to all aspects of the healthcare system.

The Healthcare System has some operational problems in itself. It might be hard to get some agreement to what the “Healthcare System” consists of, because it isn’t actually formally defined anywhere. It has been allowed to grow complex and implicit relationships so that it has become next to impossible to isolate just exactly what is going wrong. Take the ER examples discussed above. The reason we know it is a problem is because the function of the ER is defined by law—it’s a known quantity we can deal with. The rest of the definition is spread between other legislation, company contracts and industry traditions. None of this is compiled into a single document called “The U.S. Healthcare System.” Imagine if this was the case with our Air Traffic Controllers. Would you have confidence in flying, if you couldn’t guarantee that each airport handled traffic by the same set of laws?

It’s been said that the costs of the healthcare system spends about a 1/3 of its total costs on administrative tasks. Though, I couldn’t find this number specifically, I wouldn’t doubt it. From some experience with the hospital aspects of the Healthcare System, I can say that each health insurance company can have its own set of documentation which is required to be completed by the doctors, technical specialists, etc. for their patients which causes more overhead for keeping it all organized.

Aside from the paperwork problem, the challenges of mistakes and misdiagnosis also plague the system. I will lump this in with the paperwork problem because it is about how effectively the system as a whole operates. This involves not only mistakes by doctors but the interpretation of malpractice by patients. Again, we are missing a definition of expectations for the systems operation, and this vagueness seems to be leading to costly and deadly mistakes. Like the paperwork problem, since there is nothing defining how things “should be” how do we know what we can fix? This problem can be stated rather generally, “System operations are prone to failure without a clear path to resolution.”

Problem 4: System operations are prone to failure without a clear path to resolution.

These problems are a high level description whose intent is to cover with broad brush strokes the major aspects of our Healthcare Debate. I also tried to keep out any idea of solutions from those problem statements. From this set of problems we can begin to look at the system in more technical terms in a more rational way than is currently going on. In subsequent posts, I will devolve the problem into more technical terms so that we have a better chance at isolating the problem and in turn find the right technical solution.

It’s the Stupidity, Stupid.

We, humans, only appear rational. Rationality is a funny illusion that the objective parts of our minds play on the subjective parts. Think of playing a piano. We can watch a concert by the world’s best pianist and remember every detail of their behavior, but we cannot go from that observation, untrained or experienced in piano playing, and play the same, magnificent concert ourselves.

The subjective execution of the objective observation does not connect. You might argue that this is due to the “muscle memory” of the pianist which the observer would lack, and it is really a physiological limitation than a neurological one. Let’s take trained behavior out of this and meet in the parking lot.

When you go shopping for groceries, pay attention to how the cars stack up relative to the entrance door. You will find the aisle in front of the door is stacked up much higher than any other aisle, and that the number of cars in those other aisles steeply decline the further away you get from the entrance aisle. In effect, the cars distribute in a bell curve.

If we were rational, we would distribute in the shape of a semi-circle. A semi-circle is the best way for everyone to get a close as possible to the door. A bell curve is the shape of randomly behaving individuals settling about a single objective, the entrance. In the lot, we are thinking more of our objective, the entryway, not as much our geometric distance from it. Our perception is that the best place to park is the location which gives us the best view of that entrance, the aisle directly in front of it.

One way we deal with our tendency to act irrationally is to limit our behaviors so that the randomness is safely bound. The parking lot, again, is a great example of this. While we allow individuals to park in any aisle they want, no matter how irrational, we don’t seem to mind obeying the lines with in which we must park (for the most part). What happens when those lines disappear?

A friend of mine had a great example of this, pictured. This picture was taken in his work parking lot after they had experienced some rain, enough to make the already fading lines disappear. His vehicle, unfortunately for him, is the jeep stuck in the middle. Let’s remember that this is a work parking lot, which means that the individuals who are parking here do so habitually (it should also be noted that some of these parkers are engineers, who should be highly rational). Erase the lines, and the illusion of rationality disappears.

The lines in the parking lot are the physical embodiment of regulation. They are an objective, observable indicator of the legal frame within which one can park. These lines are used to make the parking lot not only an effective place to park but to enter and exit. We accept these rules because they do, in fact, make our lives easier and safer by making them less random. They are in effect the admission that our subjective minds must be bound to work in an objectively rational way.

Effective laws work by properly bounding the randomness of our behaviors so that are free to act however we want. This way we can effectively be confident that these behaviors will do no worse than only affect ourselves. However, this is not the case with out current financial system.

Unlike parking lots and street signs, the world of finance exists in a conceptual form. The boundary of objective and subjective behavior is easily muddled since the only place they are effectively measured is in the mind of those operating within those financial institutions and the regulators which observe them. We cannot easily identify when someone double-parks a derivative or accelerates their bank into a high risk situation.

We need boundaries within which randomness can safely occur; where risk can exist, but not jeopardize the safety of the whole system. Right now we are heading the wrong direction. The TARP money and the directives regarding its use are not objective boundaries, but subjective directions, telling banks how to behave. Like valets parking cars, this method may work to some extent, but it is costly, time consuming and prone to failure based on the competence of the valets.

The reason the market lacks confidence to trade is because they have just experience a multicar pile-up in their parking lot far worse than the one pictured. Piles and piles of cars (probably a semi and a few campers) are jammed in end over end and no one knows how to get their vehicles in or out. There are no lanes so no one knows who to trust for direction.

Directing bank behavior, regarding lending, is if anything a short term solution. We want a financial environment in which banks are self-motivated to make their random, subjective decisions in a safe environment. To do this, we need to establish an objective, measurable parameter all the banks can agree to, lines in the lot. Start with either eliminating high risk loan types or limiting the percentage of high risk loans any single bank can hold. Second, we need to stop the ability to mix and mask loans into things such as derivatives or other secondary types of financial tools. We must know for certain that the parking lot is for parking cars and nothing else.

The function of loans is fundamentally to give a short term resource to help individuals get towards a long term gain. Any activity with that loan, derivatives or other kinds of repackaging, is fundamentally betting on those loans’ successes or failures and should be treated as gambling. Gambling on the success or failure of one’s fiscal solvency is also part of the challenge with the stock market as well. Tools like short selling also do this same thing with the stock values. Together these bets make a very dynamic and unstable economic system.

Imagine if we started taking bets on the ability of individuals to get in or out of the parking lot unscathed. By being able to bet on the success or failure of cars to get out undamaged would mean that some individuals will be putting money on the ability of some cars to destroy others. Those gamblers’ end objective is not to get cars in and out, but to make money by damaging cars in the lot. This is effectively what our banking system and stock market have done by allowing any type of bet beyond the initial stock buy or loan to be played. What we should learn throughout our recorded history, and from the recent wars in Iraq and Afghanistan, is that destruction is far easier, cheaper and a surer bet than construction and success. The risk of the initial act of loans or stock purchase is risk enough for the system. The rules of these are clear like lines in the lot.

Our economic system needs to be sorted out with a guarantee that the lot is indeed a parking lot and not a demolition derby. Until those laws are properly set, any confidence in the market will be short term and shallow, an illusion of rationality.