The Prevention Authority and the Cost of Doing Nothing
We are, as a nation, in a surly mood. We dislike our institutions, public, private, and non-profit, we are pessimistic about the future and we are bristling with animosity toward each other. As Noah Smith recently writes, we appear to have finally soured on the one remaining institution that seemed to have some universal approval—college. Now, I’m not going to defend colleges and universities as institutions. The incredible growth in tuition, the treatment of adjuncts, the hoarding of endowment resources, etc., are acts of simple greed. As Malcolm Gladwell has said, no one who didn’t go to Harvard is defending Harvard.
But, and here’s the wrinkle, the actual production of academia has received too few plaudits. In the thirty or so years of my adulthood, the leap in knowledge generated by college and university scholars is astonishing. To just take one example from my little corner of the universe—public policy in general and the study of crime and justice in particular—the leap has been almost heroic. When I arrived on the scene in the late 1990s, the conversation in virtually every seminar was about correlations. Now, almost all the conversations are about causes.
This is a massive shift. Whereas before, policymakers and practitioners had to rely on the experts to tell them whether to believe the correlations, now they can evaluate the data themselves. As a result, collectively, we can now repeat our successes and avoid replicating our failures. And what started in seminar rooms is now increasingly the norm in governments and nonprofits. This is good, this is progress. It is not a panacea, but a necessary step in advancing the public interest. And we can thank our stuffy professors reading dry papers in dusty seminar rooms for getting us here.
Along the trail of progress, we have picked up a sturdy belt full of tools that can help to improve the lives of real people. In my little corner, it’s now possible to write down a list of 100 evidence-based proposals to reduce crime and improve public safety without engaging the justice system. Scholars in adjacent fields—education, workforce, public health, adolescent development—can write down their own lists of evidence-based things that have been causally connected to putting people on a trajectory of success. In sum, we have all sorts of data-driven, evidence-based mechanisms to prevent bad things from happening and to open doors for all kinds of opportunities.
The problem, however, is that these solutions are only a necessary but insufficient condition for action. Standing in the way of progress is one highly antiquated piece of government—our procurement systems. This part of our government is as out of date as dial-up internet. But it lingers because procurement is hardly the thing that inspires great public movements.
But here’s the thing. The cost of doing nothing is outrageously high. It is outrageously high if measured in dollars. It is outrageously high if measured in lives lost and opportunities missed, and problems not solved. Because right now our procurement system is designed only to fix things that are broken. It is only designed to repair and remediate. It is not designed to stop problems before they start. It is not designed to facilitate opportunity. It cleans up mistakes that were made because they weren’t prevented in the first place.
So, here’s another idea based on some things those stuffy professors reading dry papers in dusty seminar rooms came up with more than a decade ago—the Prevention Authority. A solution to the cost of doing nothing.
The Prevention Authority
In the last decade, there has been a recognition that governments alone, nonprofits alone, and markets alone cannot address the social ills that are still all too common features of life in America. These social ills are not hurdles on the way to a better life—these are all too often impervious barriers to human achievement. At the root of many social ills is the lack of economic and social mobility caused by a deficit of opportunities. This is a complex endeavor.
The scale of the solution must match the scale of the problem.
Here, we[1] propose an infrastructure solution that leverages the knowledge gained from a decade of partnerships between impact investors, governments, and data-driven service providers. The infrastructure solution is the creation of public-private Prevention Authorities that directly access capital markets and link those resources to evidence-based programs and practices that create the opportunity for mobility from jobs to careers, from education to knowledge, and from poverty to prosperity.
The Opportunity Gap
As I’ve talked about before, most proposed solutions to social problems focus on one thing at a time and one thing in isolation. But a lack of opportunity results from many things, and they are perniciously interrelated. For too many people, the damage begins in childhood when people are hurt by their early experiences. The stress related to childhood experiences of poverty, instability, and trauma interferes with children’s ability to develop needed academic, social, and emotional skills. This results in a cascading pattern of lack of attachment to school, social isolation, and risky behavior including drinking and drug use. The problems compound as individuals grow into adulthood and new barriers emerge—chronic poor health, obesity and disability, low educational attainment, and a weak attachment to the labor market where jobs are worked rather than careers being pursued.
Chronic diseases such as heart disease and diabetes are caused or exacerbated not only by lifestyle risk factors but also by limits on access to healthy food and opportunities for exercise, and, also by physiological changes wrought by the stress experienced in childhood. The results of these experiences impact the next generation. We have known for decades that histories of maltreatment and the chronic stress of poverty and discrimination can interfere with parents’ ability to nurture their children. Recent studies suggest that trauma can have effects on gene expression that can be passed on even to generations that do not directly experience the trauma[2]. In other words, the potentially devastating impact of our societal failures may harm future generations at a genetic level. Thus, the opportunity gap persists indefinitely.
Evidence-Based Prevention is a Mechanism for Shared Prosperity
Fortunately, there are evidence-based, data-driven solutions to create opportunities and reduce risk. These transformational approaches are built around prevention. In academic circles, in social science, medicine, and public health, there is little controversy that evidence-based prevention policies and practices can reduce costs and improve outcomes at the population level as compared to current remediation-based public policy. An ounce of prevention is indeed worth a pound of cure. High-quality implementation of evidence-based prevention programs can produce a startlingly large benefit-to-cost ratio.
Despite the strong economic case for prevention, there is widespread agreement that it is materially underfunded. Prevention is substantially underfunded because of structural impediments to proactive budgeting. Two- and four-year election cycles prioritize narrow interventions over population-level prevention and privilege short-term outputs over distant outcomes. It is simply easier to navigate the waves than to try and change the tide. Prevention requires a long-term, strategic investment that cuts across budget cycles and partisan politics. In sum, prevention requires a stable infrastructure, preferably outside of the highly politicized operating budget.
What is needed is a new financing mechanism.
Delivering Evidence-Based Prevention at Scale
Capital budgets have long been the solution to similar problems of funding long-term public interest projects with high fixed costs. Establishing Prevention Authorities at the state, county, and municipal levels of government will facilitate the widespread adoption and implementation of demonstrated prevention strategies. A Prevention Authority would build a bridge between big evidence-based ideas for comprehensive policies and practices to promote opportunity and their implementation. But building a Prevention Authority requires much more than a government-led intervention, it requires a true public-private partnership, building on principles of impact investing to achieve both scale and sustainability.
The revolution in access to the capital markets pioneered through Pay for Success (PFS) and Outcomes-Based Financing provides a foundation to build this ambitious platform. The Prevention Authority follows the model of incentivizing private and nonprofit investors to do well by doing good, through public interest investments in evidence-based programs with predictable and measurable outcomes. A decade into this movement, it is clear that these financial products must be true partnerships with the government, as governments hold the key to a partnership's success through its direct connection with target populations.
Prevention Authorities may also help advance the PFS movement by creating a new path for these products. Last decade’s innovations struggled to scale because they did not necessarily solve a problem for governments. Governments were enticed into these arrangements instead of formulating them, and thus the governments too often participated as an interested observer rather than a dedicated partner. The Prevention Authority addresses a substantial problem for the government head-on thus facilitating a much deeper involvement. The central problem the Prevention Authority solves for governments is how to meet the capital needs of disadvantaged populations within the constraints of politically determined budgets.
Breaking out of the Budget Cycle Dilemma – Prevention as Infrastructure
There is ample precedent for a Prevention Authority. For decades, cities, counties, and states have routinely created and sustained quasi-governmental ‘Authorities’ to manage big infrastructure projects. Typical examples include public housing, water and sewer, sports and entertainment, and transportation authorities. These authorities participate directly in capital markets by issuing a public bonds with long-term yields: bonds with a 10-year maturity (or longer) are common. Bondholders are compensated with coupons from dedicated revenue streams produced by the capital investments including rents (housing), tolls (transportation), and fees (water and sewer). It is not at all unusual for a large US county to hold a multi-billion-dollar bond portfolio. A Prevention Authority could identify, finance, and implement long-term, population-level investments in public health, public safety, and other public interest prevention projects.
In most states, a Prevention Authority can be established by the state legislature similar to any other transportation, water and sewer, or stadium authority and given a defined mission, oversight, and fiduciary roles and responsibilities. While extending traditional bond funding to prevention requires a conceptual leap, the practical steps are straightforward, and the path is well-defined. What differentiates the Prevention Authority is the process for identifying rigorous, transparent, and objective evidence to select a portfolio of prevention programs, and how the financing of these investments is structured.
In terms of identifying the programs, projects, practices, and policies to be funded by the Prevention Authority, there is a large, sophisticated, and growing but largely under-utilized reservoir of knowledge. The federal government has sponsored meta-analyses (statistical studies combining the results of many research studies) on crime prevention, mental health and use disorders, and education. Foundations and nonprofits have created similar clearinghouses on healthy youth development and prisoner reentry. States have developed their clearinghouses as well, including the California database on evidence-based child welfare programs. The Washington State Institute for Public Policy has taken the additional step of creating a cost-benefit model that statistically joins the meta-analysis with economic data to predict expected costs and benefits from implementing evidence-based programs at scale. The Pew Charitable Trust and the MacArthur Foundation have created the Results First Initiative to bring all of these resources together and to provide technical assistance to more than a dozen states. In sum, the knowledge infrastructure necessary for the Prevention Authority already exists.
Prevention as Pathfinder
The proposed Prevention Authority would be a natural evolution of impact investing and the double bottom-line goal of serving the public interest while achieving profitability. Several examples of Prevention Authority-like platforms have already been successfully implemented. The most notable example of a quasi-governmental ‘Authority’ is the International Finance Facility for Immunization (IFFIm) which funds the Global Alliance for Vaccines and Immunisation (GAVI), a partnership of 11 nations and the World Bank and UN. Worldwide, GAVI has immunized more than 700 million children. In the United Kingdom, Big Society Capital was established by, but is independent of, the UK government, and manages a £5 billion fund to invest in evidence-based programs typically implemented by philanthropy with more than 5,000 transactions to date. Smaller-scale examples of special funds and trusts abound in municipal government.
A Commitment to Opportunity
Prevention requires a substantial upfront investment and a long-term, sustained commitment. This requires that prevention is a core belief of government, with prevention embedded in systems and structures. This also requires a foundational commitment to the promotion of equity and healthy development across all people, regardless of race, ethnicity, or socioeconomic status. But, prevention cannot be implemented a la carte, within disconnected agencies holding a fragmented worldview. It must be sustained across the whole person over their entire life course, and to all members of a community and the community itself, through a system dedicated to their individual and collective wellbeing.
The scale of the problem caused by widespread gaps in opportunity is enormous. The solution must address the causes of these gaps at the same scale. Prevention Authorities have scale woven into their DNA and thus have unparalleled potential as a platform to close the opportunity gap.
On Another Topic
Everywhere you look on the internet, there’s bad data on crime and the risk of crime. Many cities do not make any crime data public. Or, they post crime maps instead of letting you see the numbers. This is really bad—crime maps can be incredibly deceptive if the highlighted areas exaggerate the size of the area where crime occurs (which many do)—a robbery that takes place on a single street corner can appear on a map as consuming a whole neighborhood. Lumping in all crimes together (especially on maps) is another go-to scare tactic—in a typical year, about 60% of reported crimes are larcenies (petty thefts). And don’t be confused, if someone is showing you ‘crime statistics’ and they don’t show you the actual data and some idea of the historical trend, they are most definitely trying to scare you.
So, into this void of data, many have rushed. Just put ‘crime near me’ into the ol’ Google and you’ll find them. My favorite though is ADT, which has “The ADT Interactive Crime Map that “helps you understand as much as possible about potential crime in your city or local neighborhood.” They also report “Top US Crime Statistics” which they say will help you in “understanding the city you live in or are traveling to can be key to staying as safe as possible… Check out some surprising statistics below from four major US cities.”
So I clicked on New York City. Here’s what I found:
If I’m traveling around New York City, I don’t really care about burglaries. I probably care about robberies though. Robberies being the thing that might happen to tourists in Times Square and burglaries being the thing that might be happening back at your home. When I first came across this, I wrote lots of snarky things about ADT, but at the end of the day, this mistake is so dumb it’s not worth wasting good snark on. But it’s really dumb. If someone wants to tell you about crime at the same time they are selling you something, it’s time to bring out the snark.
Musical Interlude
I might have mentioned that the missus and I have been following Springsteen around this year and our part of the tour is about over. So, I feel a deep obligation to share the joy of witnessing the greatest rock and roll song ever written.
Let the broken heart stand,
It’s the price you gotta pay
[1] The Prevention Authority idea is a joint production with Sharon Kingston at Dickinson College and the National Prevention Science Coalition. This essay draws heavily on a concept paper Sharon and I wrote here.
[2] Shonkoff, Jack P., Andrew S. Garner, Benjamin S. Siegel, Mary I. Dobbins, Marian F. Earls, Laura McGuinn, John Pascoe, David L. Wood, Committee on Psychosocial Aspects of Child and Family Health, and Committee on Early Childhood, Adoption, and Dependent Care. "The lifelong effects of early childhood adversity and toxic stress." Pediatrics 129, no. 1 (2012): e232-e246.