MEGAN MCARDLE: THE VALUE OF HEALTH-CARE EXPERIMENTS:

Ezra sees these as the beginnings of the sort of experimentation that is going to allow us to figure out what works, and thereby control health care costs. I see them as admirable local efforts that are unlikely to go anywhere.

The history of social science–very much including public health studies–is littered with exciting programs that promised to both significantly improve the lives of the targeted populations, and to save money. Yet you will notice that spending on things like health care and education is still going up, while the major reforms that have succeeded in either changing lives or controlling costs have been extraordinarily blunt: things like the EITC, where we just give poor people money; or welfare reform, where we stop doing so.

Why don’t we have more revolutions in human affairs? For starters, because these revolutionary studies are usually working with a pretty small number of patients. This means that there’s going to be a lot of variance–some will, by chance, show good results; some will, by chance, seem like disasters. The programs with “good results” will survive and get written up by social science journals and people like Atul Gawande; the programs that end up costing money will collapse and disappear into a welter of administrative embarassment. Note that I don’t say that this is what has happened in the case of these particular programs. The problem is, with small programs like this, it always has to be at the back of your mind. That’s one of the major reasons why promising pilot programs are so rarely replicated successfully.

You see this in education, too — there are these great principals who turn around seemingly hopeless schools, but somehow it never scales into a general approach. Maybe what matters is finding good people, and letting them do their best, without a lot of government involvement. Naw . . . that’s crazy-talk!