Preterition

Fifteen years ago, my deployment from West Point through Fort Benning and then arriving in theater via Bagram felt like more than a geographic crossing. I was going from bounded daily, weekly, and semester-length tasks and rhythms toward an unscoped mission largely mine to define. I had no specified outcomes to meet, no documented standard to be judged against, no formal structure to adapt: I had to figure out how to build all that, in a foreign place and culture, in ways that would be legible and amenable and executable for the people I worked with—but the clients were not the people to whom I would report. My reports to the two colonels directly above me in charge of the mission—one on the academic side, one on the operations side—were plans. Here were the challenges I saw, here’s what I proposed to do to start addressing those challenges, here were the projected steps to take and possible avenues for assessing success.

That’s what was on my mind as I made the transit. An Air Mobility Command chartered Atlas Air civilian 747 took us from Lawson Army Airfield via Ireland’s Shannon Airport to Ramstein in Germany (not sure whether “Armee der Tristen” is more or less appropriate than “Feuer Frei” as a reference there), where I bolted a midnight breakfast and caught the next C-17 Globemaster to Kuwait’s Ali al Salem air base, seated on the side benches since the center cargo area was taken up by tactical vehicles. The base at Ali al Salem consumed another several days of waiting for transit to Bagram via C-130, and then an MRAP ride from Bagram to the base outside Kabul. Each closing of the distance to my destination felt like it raised the stakes for a mission I couldn’t adequately imagine.

Everything about the trip’s procedures could be specified, down to the field and the carrier and the airframe and the temporary billeting. Nothing about the work could be specified up front. The colonels read the plans, specified revisions necessary for coalition and local partners, and said go. Nobody could put a number in advance on what the mission was supposed to produce—trust, capacity, working relationships with locals whom my superiors would never meet—and nobody could count it afterward either. Legibility resided in the plan: the challenges, the steps, the projections, an assessment that was itself a projection. Legibility permits certification, and what I had then I’d now call certification by plan. I’ve lately been putting together how a distinguished thread of economic reasoning underpins that pattern.

The license

Kenneth Arrow worked out the economics for medicine in 1963. A patient who receives treatment lacks sufficient expertise to judge the quality of treatment. The product of medical care—the patient’s health—is uncertain as an outcome to the physician. The institutions that grow up around the exchange aren’t market institutions at all. They provide trust and delegation, and they operate to stand in for information the patient doesn’t possess. Strict entry requirements like licensing and educational standards reduce the buyer’s uncertainty about the quality of the product by narrowing who may offer it. In a footnote, Arrow concedes that a license guarantees only training and not continued performance.

Arrow’s concession offers the pattern. The medical profession solved the credence good problem by certifying the producer rather than the product. A license attests to a path—school, residency, boards—and the path certifies the formed person. Michael Spence gave the general case its economics: the credential signals what an employer can’t observe, and it works because it costs more for the person who lacks what it signals to acquire.

When medicine goes wrong, malpractice asks whether the physician met the standard, not whether the patient recovered. The process is judged because the outcome can’t be. When I was in Afghanistan, my superiors performed the role of a credence regime: they evaluated what was available for evaluation, which was whether the path I proposed looked like a path. The standard has a dark side—the chart note written for a future plaintiff’s lawyer; the test ordered so the record shows it was ordered—and that dark side is isomorphic with a plan, as well. It took forms beyond the moments I described in a chapter on digital literacy instruction in Afghanistan. I shared dinners at the KBR chow hall with a Royal Danish Navy former submariner working as a staff logistician, who complained over fruit salad and salisbury steak with mushrooms that tracking numbers toward an undefined outcome for a project he didn’t own felt senseless. The American officers I passed who preferred to read Drudge Report at workstations inside the wire rather than venture out to meet with their Afghan counterparts serve as Arrow’s footnote: the certified party who stops performing. There’s a hint there of Hermann Broch’s suggestion in The Sleepwalkers that energy, undirected, becomes hysterical.

Medicine got its price

I recently offered “Not more transparency, but a price”: medicine got its price. Medicare prices a physician’s service on a Resource-Based Relative Value Scale, which sets the fee by the work the service is estimated to require. William Hsiao’s team at Harvard built the scale in the late 1980s by surveying physicians on the components of that work: the time a service takes, the mental effort and judgment it demands, the technical skill and physical effort it requires, and the stress it carries. A labor theory of value, in federal practice.

The price didn’t stay with the Harvard team. Revaluation runs through the American Medical Association’s Relative Value Update Committee, a panel of physicians, and Miriam Laugesen and her colleagues found that between 1994 and 2010 Medicare accepted 2,419 of the 2,768 work values the panel proposed. The ones who were being priced set their own price, and the price fell on the line the license had already drawn. Work that can be seen—a procedure, with a start, an end and a named instrument—was priced high. Work that can’t be seen from outside—listening, weighing a history, holding a diagnosis open—was priced low, a gap Christine Sinsky and David Dugdale document between cognitive and procedural care. Procedures came to denominate cognition.

I proposed that the bearer comes before the unit, incidence before magnitude. Here the magnitude arrived with the bearer already set, by a guild, and the price reproduced the line the license had protected. Pricing depends on the authority to set a price. According to Vladislav Valentinov (32), economist K. William Kapp sharpened that condition, arguing that unpriced market externalities cannot simply be assigned a single number. Instead, Kapp belonged to a tradition seeking to replace market exchange values with politically determined social use values. Medicine got a price, set by the priced. The relative value unit does not indicate whether, for example, cognition is worth more or less than surgery. It indicates only who was present when the number was written.

What the university certifies

A degree certifies a path. That path was commensurated into the unit of the credit hour. In 1905 Andrew Carnegie wrote to college presidents offering a pension for what he called “one of the poorest paid but highest professions in our nation.” The money wouldn’t stretch to every institution calling itself a college, so the Foundation wrote a rule for what counted as a college, and the rule counted professors: at least six full-time, a four-year course in the liberal arts and sciences, and four years of high school required for admission. That last criterion required a unit of high school work, and the Foundation supplied one with admirable candor. In Science in 1906 the Carnegie Foundation wrote that it was “necessary to use, at least for the present, some arbitrary definition of that term.” The provisional definition ran over a hundred years.

The unit denominated a pension fund before it measured a mind, a point Johann Neem makes in the credit hour’s defense: it was never built to measure learning. Its first job was to compensate faculty for their time. Naturally, the money followed it. Federal student aid was denominated in credit hours for decades before the government said what a credit hour was: twelve semester hours for full-time enrollment and twenty-four across thirty weeks for an academic year, at 34 CFR 668. The program-integrity rules added at 34 CFR 600.2 in 2010 finally provided a definition of the credit hour. I was writing about commodifying teacherly time after my return from Afghanistan in 2011, the year of the transit. The unit under my clock had started life as a pension eligibility rule. It didn’t remain confined to the transcript: the English 101 paper, the fifteen-week notebook and the portfolio are all sized to the course, because the course is what the institution pays for.

So the university certifies not the product of education—nobody could measure that in 1906 and nobody can now—but formation itself. A formation, produced by a path, survives the path. Academia spent a century converting formation into credit hours so it could be compensated by a pension fund and, later, by federal aid. That conversion now meets a pressure for which it wasn’t built. The product of the path can be produced without the path—a machine writes an English 101 paper—and an institution that could never read the product has lost even the pretense of reading it. The only certification that survives automation is certification of formation. The degree is the university’s license, and the credit hour is its relative value unit. The pricing happened a century ago and nobody named it.

The question, again, is who sets the price. In medicine the payer deferred to the priced, and the line fell where the guild wanted. In the university the priced deferred to the payer, and the colleges took the unit for a pension. In Afghanistan, my higher-ups asked the only answerable question: is there a plan? None of us could price what the plan was for.

References

Arrow, Kenneth J. 1963. “Uncertainty and the Welfare Economics of Medical Care.” American Economic Review 53 (5): 941–73.

Hsiao, W. C., P. Braun, D. Yntema, and E. R. Becker. 1988. “Estimating Physicians’ Work for a Resource-Based Relative-Value Scale.” New England Journal of Medicine 319 (13): 835–41.

Laugesen, Miriam J., Roy Wada, and Eric M. Chen. 2012. “In Setting Doctors’ Medicare Fees, CMS Almost Always Accepts the Relative Value Update Panel’s Advice on Work Values.” Health Affairs 31 (5): 965–72.

Neem, Johann. 2015. “Time and Money.” Inside Higher Ed, January 29.

Silva, Elena, Taylor White, and Thomas Toch. 2015. The Carnegie Unit: A Century-Old Standard in a Changing Education Landscape. Carnegie Foundation for the Advancement of Teaching.

Sinsky, Christine A., and David C. Dugdale. 2013. “Medicare Payment for Cognitive vs Procedural Care: Minding the Gap.” JAMA Internal Medicine 173 (18): 1733–37.

Spence, Michael. 1973. “Job Market Signaling.” Quarterly Journal of Economics 87 (3): 355–74.

Valentinov, Vladislav. 2014. “K. William Kapp’s Theory of Social Costs: A Luhmannian Interpretation.” Ecological Economics 97: 28–33.