Assign Rights, Describe Processes, Set Criteria, Experiment
In Does Your Company Know How It Makes Decisions? I pointed out that most people have no idea how decisions get made within their own organizations, and as a consequence the organizations lack decision-making skills. While I claimed that there were better processes available than “consensus,” I didn’t specify what those might be, or how to design them to replace the ineffective, bureaucratic, political waste of energy that constitutes most organizational decision-making processes in American organizations.
Now is a good time to correct this oversight.
What is a decision?
Although people probably make hundreds of decisions a day, few have thought about, or are able to describe, what constitutes a decision. Ask a dozen people in your company, and several of them are going to tell you something like, “A decision is when you make up your mind about something. It’s when you make a choice, from among several different alternatives.”
But choices are prerequisites to a decision. They might provide some satisfaction of relieving uncertainty or anxiety, but they are not decisions.
A decision is an irreversible commitment of resources.
It’s not a decision when my niece makes a declaration at the family holiday picnic, “I’ve decided I’m moving to New York to pursue a new career as an actress!”
Although her relatives might cheer her on and make encouraging noises, until she commits resources (time, energy, money) that create opportunity costs, her declaration is a fantasy, not a decision. To elevate her career aspirations from her imagination to reality, she must make commitments that will be difficult to undo. For example, she might sign a lease on an new apartment and pay a security deposit, strengthening her decision to move. She might audition for roles, committing time, energy, and putting herself at risk of rejection, to strengthen her decision to pursue a new vocation.
Her problem is that making public declarations of intent is much more rewarding, with less effort, than an irreversible commitment of resources.
Too many business managers are like my niece. They fantasize out loud about their aspirations, or make solemn declarations about change, but they never commit resources. They want the temporary satisfaction of a false resolve, so they announce public resolutions that reward their brains with the dope hit of false accomplishment, without incurring the expense, sacrifice, or risks of making commitments.
It’s not a decision until you’ve made an irreversible commitment of resources.
Who in your organization gets to make decisions?
As organizations grow, they become further and further removed from the people who founded them. The problem is that the people who founded the organization have excellent judgment about what constitutes a good idea (or the organization would never have succeeded), and the people who join the organization as it grows do not.
And how did these wise organizational Founders develop their excellent judgment? Typically, by making and learning from many mistakes.
Then, once the organization figures out what’s working and it becomes profitable and growing, the patience for mistakes wears thin, and institutional controls creep in to reduce the possibility of errors. We call these controls “bureaucracy” and it is this system of policies and procedures that constitute and enforce these controls.
Bureaucracies substitute rules for judgment.
The problem with error-minimizing bureaucracies is that so few people in the organization are permitted to make the mistakes necessary to develop their own excellent judgment, as the entire organization becomes preoccupied learning and conforming to the rules.
In bureaucratic organizations, their are few decision makers, because the policies, processes, and rules remove alternatives. For example, in No Rules Rules: Netflix and the Culture of Reinvention (Hastings & Meyer 2020) Netflix CEO Reed Hastings tells a story about an executive at one of Hasting’s earlier companies who was infuriated by a travel policy that refused to reimburse him for a $12 taxi fare.
The travel expense refusal wasn’t a decision made by an individual at the company. It was a rule that absolved any travel account manager from the responsibility of exercising judgment. And there were no compensating rules that empowered anyone in the organizations to override it!
Most bureaucracies do not allow decision making. They operate by approval, in which managers at upper levels review resource allocations to ensure that they comply with policies. Eventually, you get a corporate culture like the one satirized in the 1985 movie Head Office.
To make better decisions, organizations must assign decision-making rights to the people in the organization and foster an environment that encourages them to experiment, make mistakes, receive feedback, and improve their judgment.
Most organizations have no idea how to do this.
For example, the first purchase I made right after I secured my very first National Science Foundation grant was an electric pencil sharpener. I wanted the sharpener so that I could take notes on the manuscripts and books I was reading for my dissertation. Because I wasn’t authorized to make such purchases, I put in a request that was subject to at least four different levels of organizational approval.
These multiple levels of review are intended to avoid fraud and misappropriation of grant funds, which (upon rare occasions) has been a legitimate problem in the past. In fact, almost all purchases at my home University were treated like suspected fraud, no matter who initiated the purchase — because no one in any typical University organization is really authorized to commit $20 to the purchase of a pencil sharpener. We’re only authorized to initiate a series of reviews and approvals of proposed purchase commitments.
By contrast, almost any idiot in a University can call a meeting. And meetings, when you consider the salaries paid to the employees who show up for them, are much more expensive than pencil sharpeners.
To empower people in your organization to make decisions, you must communicate to them the resources they have the right to commit.
And not all resource commitments will come with a receipt.
What is your organizational decision process?
After your organization learns to recognize what decisions are, and who within the organization has the right to make them, it’s important to give the people in your organization some guidance regarding how to make good decisions. For example, in Only the Paranoid Survive: Lessons from the CEO of Intel (Grove, 1988) Andy Grove describes the process by which production resources were allocated among different product lines at Intel Corporation.
Production managers at individual production facilities were already empowered to commit resources to either memory chips or microprocessors. To guide their decision, they had information about sales prices, production costs, and gross margins. The managers were directed to make decisions that would increase production of the most profitable products, according to the data available for their factory.
While almost everyone at Intel at the time thought of themselves as memory chip manufacturers first, and microprocessors as an accessory to the memory business, the production managers were getting data telling them that the microprocessors were more profitable. So they allocated additional resources to microprocessors, and fewer to memory, because their decision process was to gather data and reallocate production resources to the more profitable products.
When Grove finally made a commitment to exit the memory business altogether, he discovered that his managers had already put Intel on that path, by shifting the company towards microprocessors. This sped Intel’s transition, and according to Grove, probably saved the company additional losses from the crippling competition in the low-cost memory market.
In other words, Intel already understood that a decision is an irreversible commitment of production resources. They already assigned decision rights to the production managers. And they’d provided sufficient guidance to managers about the decision-making process that when the corporation was faced with what felt like an existential crisis, the managers had already been steering production towards a resolution.
Nevertheless, the Intel example is an oversimplification. To create a more general process for a broader range of decisions, we must understand the two critical dimensions of decision-making: 1) speed, and 2) scale.
Speed refers to pace of the decision. Some decisions happen fast and frequent, while others take longer. The processes that work well for fast, frequent decisions are different from those work for slower decisions.
Scale refers to the number of people engaged in the decision-making process: individual, group, or larger society. Design processes that work well for individuals will differ form those that work well for large groups.
The two scales relate to one another, as shown in the Figure above. The more people engaged in the decision-making process, the longer the decision typically takes. For example, in the Intel example, the production allocation decision resides in the middle of the figure, near the midpoint between fast and slow, because Intel established a data-driven process that was executed at the scale of small groups of plant managers.
To improve organizational decisions, processes must be designed that apply to fast decisions made at the individual scale, as well as for slow decisions made at the collective scale.
In the lower left-hand corner of the figure, where individuals make instantaneous decisions, processes rely on a sense of identity. For example, a vegetarian doesn’t have to think about whether they’re eating meat today. Because they identify as a vegetarian, they’re just not a meat person.
This is why twelve-step addiction recovery programs begin with the identity statement: “I’m an alcoholic… and my life has become unmanageable.”
The first part of Step 1 is a powerful rational for making the decision to stay sober, while the second part reminds the alcoholic that their current decision-making processes were not working for them and they need new processes that will support their new identity.
Eventually, after weeks or months of practice, better decision making will become a habit.
Because identity is so important to rapid decision making, organizational leaders must make a consistent effort to create a strong sense of identity for those in their organization. This is why we have job titles and descriptions, so that people understand who they are in relation to the organization, and what their role within it is. The stronger their sense of identity, the faster their identify-based individual decisions.
Moving towards the middle of the figure, where policies and rules are found, decisions are made at a larger scale. This is the scale at which bureaucracy operates, and most readers have so much experience with bureaucracy that it’s of little further interest to us now. The key point to remember is that bureaucracy is an attempt to simplify the process of group decision making to make it less expensive and more reliable.
That comes with consequences at slower speeds and larger scales, where bureaucracy no longer functions.
What gets really interesting are judgment, GFN and the social process that couples them: deliberation. To the extent that judgment is about knowing when to break the rules, it stands in opposition to bureaucracy. And it provides room for creativity and innovation.
While I can’t say what sort of creative, analytic-deliberative decision-making process will work for your organization, I can describe for you the processes that work at our little startup company called Morozko Forge. We manufacture the world’s first ice bath. (Our competitors are cold baths, because we’re the first and still the only that reaches freezing temperatures).
The Morozko decision-making process has two important stages. The first is to identify and formulate the problem you are trying to solve. The second is to share lots of ideas and speculate about the consequences in a process we call “What if?”
What problem are you trying to solve (and why is it important)?
When Steve Jobs launched the iphone over 10 years ago, he was explicit about the problem that the iphone solved for mobile phone users. Most people didn’t even know they had a problem… until Jobs showed them the Apple solution.
And that’s the value with asking ‘What problem are you trying to solve?’ Most people are so pre-occupied with their own solutions that they forget what problem they’re trying to solve. They lose their focus. They dilute their efforts, and as a result they wind up with lots of great solutions for problems that don’t exist.
I had an exchange with one subordinate who was two hours into an inventory solution without an understanding of the problem. Instead of asking, “What problem am I trying to solve?” this subordinate (and others) kept researching solutions to problems we didn’t have.
As a start up company, our survival depends upon our ability to identify, formulate, and solve important problems. When we lose track of the problem we’re trying to solve at any particular moment, we’ve lost our path to profitability.
In another exchange, a particularly clever and creative subordinate wanted to show me a new heat exchanger design he had just finished prototyping. He was beaming with his preliminary results, and he wanted to share them and improve the idea further.
But I interrupted him and asked, “What problem are you trying to solve?”
He said, “Oh, I don’t have a problem!”
And I lost my temper, at least a little bit… because all of his creative energy could take us in the wrong direction if he wasn’t able to improve his capacity to identify, formulate, and articulate problems.
I scolded him:
Well, that sucks from me that YOU don’t have a problem, because our future as a startup depends on our ability to identify, formulate, and solve problems that make life better for our customers, and I have about 99 problems I’ve got to attend to, and here you are — one of our brightest and most clever companions — and you can’t find one single damn problem inside our company to be working on?
He understood right away that his enthusiasm for his new solution had caused him to lose sight of the problem he was working on, and that his response was a reflex instead of an explanation.
When we use the prompt, “What problem are you trying to solve?” we sometimes activate an emotional, defensive response. As children, we learn that teachers, parents, bullies, and other authority figures will threaten us with the challenge:
What’s your problem?
Many of us learned to avoid conflict and confrontation by saying, “I don’t have a problem,” and that’s exactly what my subordinate found himself doing when he was trying to present his new prototype. In fact, this type of conflict-avoidant behavior is exactly why most organizations suffer from a failure to identify and formulate important problems.
In this case, my clever engineer regained his composure, restarted his presentation with “The problem is that our units take too long to cool down in hot Phoenix summers, wearing out our compressors and disappointing our customers.”
Now that’s a problem for which I have a lot of patience and creative energy!
After we understand the problem we’re trying to solve, it’s time to generate solutions. It’s OK if we start with crappy solutions, because each idea could lead to a better one.
One of the things that is a comfort to me when brainstorming for new solutions is reminding myself:
My first idea is rarely good enough.
By asking, “What if… ?” we think through the consequences of of different alternatives. We’re simply speculating at this point. We’re creating thought experiments about what would change in the world if we implemented whatever idea it is that we’re asking about.
For example, we had a leaky tub that defied our usual troubleshooting and repair protocols. So we ran a series of “What if … ?” thought experiments. It sounds like this:
What if we threw the tub away and started with a new one?
If we threw this tub away and started with a new one, we would save ourselves hours of head-scratching, we would finish producing the unit faster, we would increase our materials costs by about $110, and we would never learn about what was causing the problem and how to prevent it.
What if we used Liquid Nails Fuze-it to seal all of the seams from the inside?
If we used Liquid Nails Fuze-it to seal all the seams from the inside, it would take us an hour to apply the seal and retest the tub, and we might discover a reliable way of repairing leaky tubs and save ourselves from having to purchase a new $110 tub.
(This experiment sounded good enough to try, but our brainstorming process doesn’t stop there. We often keep going, just to see if we could improve upon the idea).
What if we used aluminum impregnated nitrile rubber to seal all the seams from the inside?
If we used aluminum impregnated nitrile rubber sealant to seal all the seams from the inside, it might take several hours for the sealant to cure before we could retest the tub, and we might discovery a reliable way of repairing leaky tubs and save ourselves the expense of having to purchase a new $110 tub.
(We decided to use both the Fuze-it and the nitrile rubber in separate experiments. The Fuze-it was faster, cheaper, and worked great!)
The whole point to asking “What if… ?” is to generate enough solutions to ensure we might find one that is good enough. Only by describing the consequences of the solution, rather than judging it, can we come to understand what a world with that solution in it might look like to us.
After a few years of implementing the “What if… ?” protocol, I’ve discovered that the most common mistake is short cutting the process by misinterpreting the question as a command.
When your subordinates respond to your “What if… ?” by saying, “OK, I’ll do that,” they have removed themselves from the decision process. And that’s going to result in a lot of inferior decisions.
By what criteria will you assess the quality of different solutions?
Once you’ve described the consequences of different “solutions”, it’s important to understand which to experiment with first. To prioritize each, we must understand the criteria by which we assess our resources commitments.
Thus, we ask ourselves a series of questions, in the following order:
Will this experiment result in new knowledge? (I.e., what might we learn?)
At this stage of our start up, knowledge is the single most important resource we have. It could be knowledge of technique, such as how to repair a tub. It could be knowledge of the market, such as customer preferences and values. It could even be knowledge of one another, and specific strengths each brings to our company.
If the experiment will create new knowledge, it becomes a high resource priority.
Will this experiment take care of our customers?
The entire point of our health and wellness company is to help people take better care of themselves. Experimenting with solutions that come at the expense of our customers is antithetical to our mission, so that doens’twon’t work for us. No one is going value a health and wellness company that does not provide knowledge and equipment for taking care of health and wellness. That doesn’t mean we do everything for our customers, because caring for our customers means empowering them and we sometimes struggle to make the distinction between caring for and doing for. Nevertheless, this question prompts us to consider how our proposed solutions might impact our customers, because:
“The purpose of business is to create customers.
— Peter Drucker.
Will this experiment take care of our companions?
To enable our customers to better care for themselves, we must exemplify taking care of ourselves. Put another way, without caring for ourselves, we cannot expect to be able to care for our customers. Solutions that come at the health and wellness expense of our companions will undermine our capacity to provide the necessary knowledge and equipment to our customers, and undermine our credibility in the marketplace.
Will this experiment conform to our vision of the future world in which we want to live?
Responses to this question require clarity about the future vision of the company and the change we seek to make in the world. For us, that vision includes a world that is free from Type 2 diabetes, free from Alzheimer’s, free from obesity, and free from all the maladies of modern living.
The mission of Morozko Forge is to provide the knowledge and equipment necessary to live a natural life in an unnatural world.
Not every decision we make will be on direct path towards that vision, and that’s OK. We’re not asking for the shortest path, or the best path, or even the quickest path.
When we ask whether an experiment conforms to our vision, we’re seeking to clarify our vision and the space within it for the experiment we’re contemplating. Sometimes, we won’t know the answer to this question until we run the experiment.
And other times, asking this question makes it clear that the experiment will not take us closer to the future world we seek, in which case we discard the experiment.
Might this experiment generate more resources than it consumes?
In this final question, we’re finally getting to what MBA programs might call “return on investment” — but don’t think that means we’re reducing the answer to a financial spreadsheet.
Although money is important to the health of our company, at this stage of our venture, our creative energy is even more important.
So what we’re prompting in this question is a multi-dimensional examination of the resources we’re committing to a decisions in terms of energy, time, and money, relative to the return we will realize in all three of those resource categories. When we make resource commitments that generate more energy, more time, and more money, we accumulate the resources we need to grow our venture.
Every decision is an experiment
Although I’ve described a decision as an “irreversible commitment of resources,” that doesn’t mean we can’t make a different decision later. It only means that the resources we’ve committed to the previous decision can’t be recouped.
A new decision might commit additional resources to undo the previous decision, and that’s OK — even if it gets expensive sometimes.
Thinking of everything decision as an experiment gives us the freedom of being wrong without the anticipatory anxiety of regret.
In Designing Your Life (2016) Stanford Professors Bill Burnett and Dave Evans encourage readers to think of commitments as experiments that allow trying new things, learning, and trying again. They argue for the application of what’s typically called “design thinking” to personal and career choices.
The difficulty with this type of thinking is that you’re always going to be wrong. When you’re trying new things, you can hardly ever get it right the first time. For many, the imagined humiliation of being wrong is so painful that they’ll never do the experimenting that continue their learning. As a result, people get stuck in old patterns, old habits, and failed “solutions” that stopped working long ago — while their energy is midirected into defending themselves against the nagging suspicion that they might bear some responsibility for their own failures.
The antidote is to stop worrying about being right, and to focus instead on what you have to do to be successful.
At Morozko Forge, talking about every decision as an experiment releases us from the ego investment in being right. It helps dissolve the anticipatory anxiety of being proved wrong, and managing that anxiety is essential for the growth of our venture.
When we think in terms of experiments, rather than in terms of answers, it refocuses our energy on our most important decision question, “Will this experiment result in new knowledge?”
That’s how our organization makes decisions, by:
Assigning decision rights,
Describing decision processes,
Setting criteria for evaluating alternatives, and
I wonder if your organization might benefit from adopting some of the same practices?
Column | Troubled ‘turbantor’ Harbhajan and his aggressive instincts
The retirement of Harbhajan Singh from all forms of competitive cricket in December 2021 brought to close the career of a gifted cricketer who courted controversy at every turn of his career. During the first years of the 21st century, he was arguably the best spin bowler in the world and though his wicket-taking abilities hit a plateau after that, he sustained himself by the versatility that saw him play all formats of the game at the highest level with reasonable success. He was a regular in the national side and part of the team that won the International Cricket Council (ICC) T20 World Cup in 2007 and the ICC World Cup in 2011. Though he lost his place in the national squad in 2015, he continued playing in Indian Premier League (IPL) till he chose to hang up his playing boots last month.
Harbhajan kickstarted his career during the 1997-98 season when he found himself playing for the national side in March 1998 within four months after making his debut for Punjab in Ranji Trophy. His performances at the junior level and the absence of top quality off-spin bowlers were factors that prompted the selectors to try out this rookie bowler, then still in his teens. He did not set Kaveri on fire on his Test debut, which took place against Australia at Bangalore. Within one month, he made his bow in One Day Internationals (ODIs) as well but a string of below-par performances saw him lose his place in the side soon thereafter.
After going through a period of near oblivion when he was also thrown out of a training programme in National Cricket Academy on charges of indiscipline, Harbhajan staged a comeback to the national side in the winter of 2000-2001 with a performance that will be remembered by followers of the game in India for all times. Australia, led by Steve Waugh, had landed in India to conquer the “final frontier”. The visitors were on a high, having won the previous 15 matches on the trot and looked forward to creating a new world record with 17 consecutive triumphs in Tests, while also winning the series. And when they won the first Test at Mumbai by a margin of 10 wickets, everyone thought that they were on their way to attaining both their goals.
The Kolkata Test against Australia in February 2001 is known as “Laxman’s Test”, for his knock of 281 runs in the second innings which helped India to script a magnificent turnaround and win this game, after trailing in the first innings by 274 runs. Harbhajan also had a crucial role to play in this victory as he took 13 wickets (7 for 123 in first innings and 6 for 73 in the second), including a hat-trick on the first day. In the last Test at Chennai, Harbhajan again played a stellar role, bagging 15 wickets for 217 runs (7 for 133 in first and 8 for 84 in second innings) to finish the series with a tally of 32 wickets. Aussie batsmen did not have any answer for his wiles and even such accomplished performers as Rickey Ponting and Adam Gilchrist appeared shell-shocked while facing him. Australian media nicknamed him as “Turbanator”- a tribute to his destructive capacity with the ball.
Harbhajan’s career did not ever attain the stratospheric heights that this performance promised. The surfeit of limited overs’ cricket made him focus more on restricting runs than on “buying” wickets. This resulted in bowling a flatter line without “giving the ball air”; the classic loop which is the hallmark of a top-class off-spinner also disappeared. This made him a less destructive bowler except on helpful surfaces and the returns also started growing thinner. When Anil Kumble returned to the side after recovering from an injury, Harbhajan moved into the slot of support spin bowler.
A finger injury caused Harbhajan to return home during the tour to Australia in 2003-04. He returned to the side the next season and was amongst wickets with most of the games being played at home. However, the arrival of Greg Chappell as coach and the exit of Sourav Ganguly as captain of the national side in 2005 caused hiccups in Harbhajan’s career. He was the first Indian cricketer to publicly criticise Chappell and his methods and said that the coach was “instilling fear and insecurity” in the side. Though his explanation was called for, Harbhajan managed to escape action and issued a statement lauding Chappell soon thereafter!
Harbhajan found himself in the midst of one of the biggest controversies in cricket when India toured Australia in 2007-08. In the second Test at Adelaide, Australia lodged a formal complaint that he indulged in racial abuse against Andrew Symonds. The relations between the two sides were at a low ebb and this incident even threatened to disrupt the conduct of the remaining part of the tour. Harbhajan vehemently denied the charges and the Indian team management supported him. But Mike Proctor, the match referee, found him guilty and slapped a punishment. India promptly appealed against this verdict and got a stay, which allowed the tour to go on. Eventually, the ICC appeals Commissioner Justice John Hansen overturned the verdict of the match referee and absolved Harbhajan.
Controversy continued to dog Harbhajan even after the closure of this episode. During the Indian Premier League (IPL) matches in 2008, he slapped fellow India teammate S Sreesanth after the game between Kings XI Punjab and Mumbai Indians, which the latter side, led by Harbhajan, lost. The slapping of a national player in full view of television cameras drew widespread criticism and Board of Control for Cricket in India (BCCI) moved fast and initiated action against Harbhajan.
Incidentally, this was not the first time that Harbhajan had got physical with Sreesanth. During the Champions Cup trophy match in 2007, he had shoulder charged the fast bowler when he was walking to the top of his bowling mark. BCCI had chosen to ignore this incident despite it being witnessed across the country. But the “slapgate” was too serious to be brushed under the carpet and Harbhajan was barred from playing the remaining matches of that season of IPL, besides a five-match suspension from ODI’s.
Harbhajan’s international career took a severe reverse when he was injured during the tour to England in 2011. He was not selected for the tour to Australia in 2011-12 and his appearances in international matches became sporadic after that. He played his last Test in August 2015 and his final appearance in an ODI took place two months later, though he continued to play domestic first-class cricket till 2017. Since then, his appearances on the cricket field were limited to playing in IPL, where he picked up 150 wickets in 13 editions.
A tally of 417 wickets in Tests and 269 scalps in ODI’s makes Harbhajan the second most successful off-spinner to play for India, after Ravichandran Ashwin. He could also wield the willow effectively as evident from a total of 2,224 runs in Tests with 2 centuries and 9 fifties. He was also the first spin bowler from India to adjust to the demands of all versions of cricket effectively. But his tendency to create controversies and lack of amenability to discipline cast a cloud over his career which could have reached much greater heights given the prodigious talent he was blessed with.
Followers of the game from Kerala could be forgiven for not harbouring a soft spot towards this highly competitive cricketer as he is considered to be the bugbear of Sreesanth and the source of all troubles that the Kochi born pacer found himself in. News reports indicate that the two cricketers subsequently spoke to each other and resolved their differences. But it would be difficult for the fans to forgive so easily as the bad taste created by those incidents does not vanish quickly. The same is the case with cricketers and cricket-loving public of Australia, as could be understood from the observations in the autobiography of Gilchrist, despite Harbhajan and Symonds sharing the same dugout in IPL.
In retrospect, one is forced to conclude that it would have been better for Indian cricket if the aggressive instincts of Harbhajan Singh were channelled properly on the cricket field and outside.
(The author is a former international umpire and a senior bureaucrat)
Sports Betting’s Next Big Election Battles Are in California
TEMECULA, Calif. — Legal sports betting in the United States accelerated in 2021 as a flurry of states either overcame legislative logjams, as Ohio did just before Christmas, or signed off on online wagering, as New York did just after Election Day.
But those efforts are likely to pale in comparison to the all-out lobbying, campaigning and legal jousting in 2022 involving what a DraftKings executive recently called “one of the holy grails” in sports betting: California.
By November, Californians may be asked to vote on as many as four sports betting initiatives. That’s why deep-pocketed interests, including national sports books and Native American casinos, have been gearing up to spend $200 million to persuade voters in California to support their particular proposal — or to reject the others.
One measure that has already qualified for the state ballot, sponsored by powerful tribes in California, would add sports wagering, but only in person, at tribal casinos or horse racing tracks. Online betting initiatives, now gathering signatures, dangle the prospect of making bets anywhere through the internet. Others offer a middle ground.
If one of the measures passes, nearly two-thirds of Americans will live in states that allow or regulate sports betting. And with California and New York on board, sports wagering would essentially be national in scope, fueling a market that Goldman Sachs recently estimated could grow to $40 billion in revenues in a decade from $900 million now.
Yet gambling expansion in California has often fallen short or been torpedoed by competing interests. Indeed, California’s card rooms, which primarily operate around larger cities and offer a more limited range of games, just filed a lawsuit to invalidate the qualified tribal measure.
“We’re never going to get sports betting figured out at any level unless California comes on board,” Jason Giles, executive director of the National Indian Gaming Association, said at a recent sports betting conference at the Pechanga Resort and Casino in Temecula. “That will be the game changer for the United States.”
Since the Supreme Court’s decision in 2018 to strike down a federal law banning commercial sports betting in states other than Nevada, more than 30 states have authorized sports wagering, including about a dozen in the last year. More than 20 states have gone live.
New York just started mobile sports betting after awarding licenses for it to two coalitions featuring marquee names, Caesars Sportsbook and Bally’s Interactive. Gov. Mike DeWine of Ohio signed a bill legalizing sports betting in late December. And legislators in Wyoming and Arizona, among others, quickly approved sports betting.
“Look at this massive expansion across the country and where we are — it’s becoming very mainstream,” said Brandt Iden, a former state representative in Michigan who pushed to legalize sports betting in his home state. Iden is now head of government affairs for Sportradar, which collects and analyzes data for sports books. “I talk to legislators who say, you know what, I don’t support gambling, but everybody is doing it.”
Of the holdouts, Texas considered several bills in 2021, and some lawmakers expect momentum when the legislature reconvenes in 2023. Florida, meanwhile, is a mess: A federal judge recently blocked the Seminole Tribe’s new sports betting app, and DraftKings and FanDuel are racing to gather enough signatures to get a referendum on the 2022 ballot.
In California, gambling — mostly on slot machines and blackjack — has been legal for two decades on tribal lands under compacts negotiated with the state. The state also permits gambling at horse racing tracks, which was legalized in 1933, and card rooms, which trace their lineage to poker-playing miners during the Gold Rush.
Any changes would require constitutional amendments through a voter referendum, or legislation backed by the voters.
Previous attempts have bogged down; online poker, for instance, failed in part because the tribes themselves were split. But now there appears to be less resistance on moral and philosophical grounds.
“If we think about progressive legislation, or legislation to protect consumer welfare, California lies at the forefront, whether we want to talk about minimum wage or privacy protection,” said Marc Edelman, a law professor at Baruch College who has written extensively on sports gambling. “If California legalizes sports gambling it becomes very unlikely that another state would arise as the consumer-oriented opposer of sports gambling.”
This time, the push to expand gambling began before the pandemic, from a coalition of 18 tribes that have dominated casino gambling in the state.
Across the United States, tribal gambling generated $27.8 billion in revenue in its fiscal year from Oct. 1, 2019, to Sept. 30, 2020, despite the pandemic. California is the biggest state, with 66 tribal casinos on federally recognized lands, mostly far from the coast, yielding about $8 billion, with much of that coming from slot machines.
Under the tribes’ initiative, which is backed by a political action committee that has raised more than $13 million, sports wagering would be permitted at tribal casinos and horse tracks. Roulette and games played with dice, such as craps, would also be allowed under the proposal, which qualified for the ballot in May 2021 after collecting more than one million valid signatures.
One thing that is not included is online betting, because the initiative is intended to be “a very measured, incremental step,” said Mark Macarro, tribal chairman of the Pechanga Band of Luiseño Indians in Riverside County.
“We think this is the right thing to do for tribes and tribal sovereignty,” he said at the conference here. “There’s enough skittishness out there about what could happen to brick-and-mortar facilities.”
The initiative would also create a new civil enforcement tool allowing anyone suspicious of any illegal gambling operations to file lawsuits. It is this provision that has fueled two separate but related efforts by California’s card rooms to defeat the tribes, and to get their own sports betting measure passed.
California has more than 80 card rooms ranging from pub-like places with a few poker tables to sleek behemoths with 270 tables accompanied by restaurants and plentiful A.T.M.s. Collectively, they employ 23,000 people in urban areas, many of them Asian, Black and Hispanic, and pump in $300 million in federal, state and local tax revenues each year, according to the California Gaming Association, a trade group.
Many municipal budgets rely heavily on the card rooms to finance vital services and bolster juvenile justice and other programs, said Mayor Tasha Cerda of Gardena, which has two card rooms. She has backed an initiative that would permit sports betting at the card rooms, tribal casinos and racetracks, as well as allow for internet sports betting. That initiative has raised $450,000 to date. Meanwhile, some of the bigger card rooms have poured more than $24 million into a “No” campaign against the tribes’ initiative.
During a recent tour of Hollywood Park Casino in Inglewood, adjacent to SoFi Stadium, the host of the Super Bowl next month and the College Football Playoff national championship in 2023, Deven Kumar, the casino’s general manager, estimated sports betting could increase revenues — already hurt by the coronavirus pandemic — by 20 percent to 25 percent. He and James T. Butts Jr., Inglewood’s mayor, warned that the tribes’ civil enforcement provision could drain their existing business by up to 75 percent, compounded by the inevitable legal costs.
“They are attempting to make gambling a monopoly at the expense of others,” Butts said. “They are not the disenfranchised group they once were. The minority majority cities deserve the opportunity for equity as well.”
In the city of Hawaiian Gardens, where the Gardens Casino supplied 68 percent of the tax revenues in the 2019-20 municipal budget, Keith A. Sharp, the casino’s general counsel, said sports betting could transform Sundays at the casino — now mostly empty — into bustling periods where customers could wager on N.F.L. games while also playing baccarat or other games.
If the card rooms were hobbled, however, Nary Chin, a longtime card dealer and single mother of four, said she feared for her future.
“I learned English in the card room, not school,” said an emotional Chin, who immigrated from Cambodia in 1984. “I am very grateful. This is my home. If I didn’t have this job, I don’t know what I’d do.”
The third initiative comes from online sports books, including DraftKings and FanDuel, that want to enter California for the first time and offer online betting.
The measure requires those companies to partner with tribes, and its supporters say voters can pass both their initiative and the tribes’ in-person one. Most of the state’s profits would be dedicated to homelessness measures, and to the tribes themselves. It would also allow betting on nonathletic events, like award shows and video game contests, but not youth sports or elections, according to the nonpartisan Legislative Analyst’s Office.
“We view brick-and-mortar as very complementary to mobile,” Jonathan Edson, FanDuel’s senior vice president for business development, said at the sports betting conference.
“California is one of the holy grails in sports,” added Jeremy Elbaum, senior vice president for business development at DraftKings.
The supporters, buffeted by an initial $100 million from seven sports books, have lined up mayors in Long Beach, Oakland, Fresno and Sacramento, plus advocates working to combat a homeless crisis. They are confident they will collect enough signatures to be certified by the June ballot deadline.
“We are focused on ongoing stable revenue to fund the key programs that we know we need,” said Tommy Newman, vice president for engagement and activation at the United Way of Greater Los Angeles. “If we’re honest, this is regulating and capturing value from something that is happening, for people in communities that absolutely need the investment.”
In November, a fourth initiative arrived supporting both online and in-person betting, backed by a different group of tribes, including the Rincon Band of Luiseño Indians and the San Manuel Band of Mission Indians.
“Out-of-state and international gaming operators want to rewrite the balanced system California has created so that the future belongs to them, paying a pittance to serious local and statewide social problems, and trying to divide the Tribes by offering temporary riches to a few while taking future growth opportunities away from the rest,” the tribes wrote in their application to the California attorney general.
A lawyer for the tribes, Scott Crowell, did not respond to messages seeking comment.
Some gambling analysts believe that a plethora of initiatives may confuse voters, who may just say no to everything. Another wild card is a lawsuit filed in December by two card rooms claiming that the qualified tribal initiative violates the state constitution, which says initiatives can focus only on one subject, because the tribes are trying to add retail sports betting as well as add more table games.
Still, no matter the outcome of the lawsuit or the ballot measures, many sports and technology companies are building audiences through free-to-play games, contests, fantasy sports and national marketing campaigns, even in states where sports betting has not yet been cleared, said Rob Phythian, founder and chief executive of SharpLink Gaming, a technology company.
Teams like the Minnesota Vikings have hired companies like SharpLink to build fantasy games. That could be consequential in California, where there are 19 teams in the N.F.L., M.L.B., N.B.A., N.H.L. and W.N.B.A. — by far the most of any state.
“We’re just a bridge to betting,” Phythian said. “It’s sort of like training the muscle.”
Addressing maternal health inequities | AAMC
Kysha Shaw lives with a lot of uncertainty. Among other things, the 42-year-old single mother of three worries about COVID-19, schools closing, and drug use and crime in her West Baltimore neighborhood.
“I love this community, but it can be really sad,” she says. “You see people begging for shoes and clothes. You might see someone slumped over with a needle in their arm. People sell drugs in front of the convenience stores.”
But Shaw is determined to keep herself and her children healthy, which she’s done thanks in part to an innovative effort called B’more for Healthy Babies Upton/Druid Heights (BHB U/DH). Founded in 2011, the program is part of a citywide initiative and is a partnership between the local community, the University of Maryland Medical Center, and the University of Maryland, Baltimore.
BHB-U/DH supports mothers and babies in West Baltimore, where 92% of residents are Black and 66% of children live below the federal poverty level. It provides prenatal education, support groups, smoking cessation, some rental assistance, and connection to a range of social services. Among other achievements, the effort has reduced infant mortality by 75%.
Experts believe that programs like BHB U/DH are essential if the United States hopes to address the inequities in maternal health found in so many crowded cities and remote rural towns.
The statistics are striking: Black and American Indian/Alaskan Native women are two to three times more likely to die from pregnancy-related causes than White women. Black women are twice as likely to experience serious perinatal complications. And early indicators suggest that COVID-19 is only exacerbating such inequities.
What’s more, advanced degrees and full bank accounts don’t close the gap. In fact, a college-educated Black woman faces a 60% greater risk of maternal death than a White woman with no high school diploma. Why is that? Experts point to the effects of subtle and explicit racism as well as weathering, the biological fallout of ongoing stress that can cause premature aging and related health problems.
Faced with this worrisome reality, researchers and providers are working to improve the health of vulnerable pregnant people before, during, and after childbirth.
“It’s incredible, some of the things I’ve heard our moms go through when they’re seeking care. It’s heartbreaking.”
Kamilah Dixon-Shambley, MD
Medical director of Moms2B
“Inequities are so pervasive and persistent that they require multisector efforts,” says AAMC Health Equity Research Analyst Funmi Makinde, MPH. “We need to address transportation, employment, and housing as well as physician shortages, and we need more diverse providers. We need high-quality data that are shared publicly to ensure accountability. The list goes on.”
Throughout all this work, it’s crucial to include the perspectives of patients who are often overlooked, experts say. In one recent survey, 20% of Black, biracial, and Latinx people felt their medical requests were refused or ignored, compared with 11% of White people.
“It’s incredible, some of the things I’ve heard our moms go through when they’re seeking care. It’s heartbreaking,” says Kamilah Dixon-Shambley, MD, medical director of Moms2B, an Ohio State University Wexner Medical Center program that provides yearlong supports and health education to low-income new and expectant mothers. “It’s crucial that patients and the community can trust their providers.”
Below, AAMCNews profiles multifaceted efforts to address maternal health inequities across the country.
Data that save lives
In 2006, California officials noted a worrisome trend: Maternal mortality was on the rise, even as the state recorded the most births nationwide.
Hoping to reverse the disturbing death rate, they turned to Stanford University School of Medicine to co-found the multistakeholder group that became the California Maternal Quality Care Collaborative (CMQCC).
Serious number-crunching has fueled much of the CMQCC’s work. For one, it collects and analyzes hospitals’ raw data to quickly identify areas ripe for improvement, including racial and ethnic disparities.
“We send hospitals back reports, and they are flabbergasted when data are broken down by race and ethnicity. They may see that their Black patients have 6 percentage points higher C-section rates than Whites,” says CMQCC Medical Director Elliott Main, MD. “That really spurs them on to look at addressing racism in labor and delivery.”
CMQCC experts also use data to identify the need for and then create step-by-step provider toolkits on key causes of birth-related complications. One on postpartum hemorrhage, which covers such crucial moves as measuring and effectively treating blood loss, reduced disparities between Black and White patients by nearly 80%.
“The standardized protocols in toolkits take away a lot of provider subjectivity,” Main says. “Subjectivity is the entrée for biases that impact patient care.”
And hospitals in the collaborative — there are more than 200 of them — can receive training on implementing the toolkits. “A toolkit that sits on the shelf does nothing,” he adds.
“We send hospitals back reports, and they are flabbergasted when data are broken down by race and ethnicity. … That really spurs them on to look at addressing racism in labor and delivery.”
Elliott Main, MD
Medical director of the California Maternal Quality Care Collaborative
All of these efforts have borne fruit: Since the launch of the collaborative, California’s maternal deaths have dropped by 65%.
Now, the CMQCC is crafting additional equity-related recommendations, such as handing expectant patients a staff-signed commitment promising to treat every patient with dignity and engage them in all birth-related decisions.
Also high on the CMQCC agenda is assessing the approaches of maternal mortality review committees, the bodies that study every pregnancy-related death.
“Often a problem is that review materials are medical-centric, and obviously the patient can’t tell her own story,” says Main. “We’re now exploring interviewing family members who lost a relative for their perspective. I think that’s going to be the future of committee reviews.”
Pregnancy always brings some stress, but the tension is much higher for patients who struggle to understand English and the intricacies of the U.S. health care system.
That’s why Crista Johnson-Agbakwu, MD, founded Valleywise Health’s Refugee Women’s Health Clinic in Arizona in 2008.
Since then, the Phoenix-based center has served more than 16,000 patients, many from countries across Africa. Arizona, which ranks high on the list of states resettling refugees, is now integrating evacuees from Afghanistan, says Johnson-Agbakwu.
“These are people who have escaped war and gender-based violence and other human rights atrocities,” she notes. “It’s important to understand the communities’ needs and meet the priorities they identify.”
To help do that, the clinic hires cultural health navigators (CHNs) — lay health care workers steeped in the culture and language of those they serve. “CHNs deeply understand patients’ background, religion, and lived experience and can interpret their health care through those lenses.”
CHNs offer patients ongoing supports, from accompanying them to prenatal visits to facilitating a smooth hospital discharge. And they can chart all interactions in electronic health records so that physicians know what’s been done or discussed.
“These are people who have escaped war and gender-based violence and other human rights atrocities. It’s important to understand the communities’ needs.”
Crista Johnson-Agbakwu, MD
Founder of Valleywise Health’s Refugee Women’s Health Clinic
Like Baltimore’s BHB, Ohio’s Moms2B, and similar programs, the clinic’s supports are accompanied by classes on perinatal health. But its offerings include a tour of the hospital labor and delivery unit — a crucial support for participants unaccustomed to Western, medicalized births.
“Things like IV lines and beeping noises and blood pressure cuffs can be very scary for this population,” says Johnson-Agbakwu. “They’re used to being mobile in labor and can interpret what we do as tying them to the bed. The tour helps demystify a lot of this.”
In all its work, the clinic strives to honor patients’ perspectives. “We try to go beyond checking the boxes of ensuring medical care,” she says. “We are engaging in care that’s anchored in mutual respect. That’s a piece that can be missing in achieving maternal health equity.”
Reaching rural patients
Many of the patients treated by Vidant Health in eastern North Carolina face significant pregnancy-related risks. More than half are overweight or obese, and many have diabetes or hypertension. The poverty rate of this population is twice the national average, and nearly all live in remote rural areas.
Black people — who comprise roughly a third of Vidant’s birthing patients — often fare the worst. In one recent nine-year period, they represented nearly 70% of maternal deaths in the region.
And Vidant Medical Center, based in Greenville, is the only large hospital in an expanse covering 29 counties.
Since 2017, Vidant has been working to support providers throughout the region in efforts to ensure high-quality care during obstetrical emergencies.
One major focus is drills in birth-related crises. These simulations — hundreds have been held in 18 hospitals over the past three years — cover emergency cesarean sections, maternal resuscitation, and more.
The scenarios unfold realistically: A Vidant staff member assumes the role of a patient, and the local team races to save her — calling for emergency assistance, rushing to get instruments, and suggesting necessary maneuvers.
“In a small hospital, these emergencies happen maybe once every two or three years,” which makes it tough to keep skills fresh, says James deVente, MD, PhD, medical director of obstetrics at Vidant Medical Center. “We give them a chance to practice skills over and over so that when something actually happens, they’re ready.”
Traveling to provide training is not always the best option, though. So Vidant providers have also logged thousands of hours advising local providers on how to handle their toughest perinatal cases.
Now, in an effort launched in July 2020, Vidant experts also remotely treat high-risk patients, working in collaboration with 15 local obstetricians.
“Patients often need to drive 60 miles or more each way to be seen [at Vidant],” says Alan Sacks, MD, who heads the Maternal Outreach Through Telehealth for Rural Sites (MOTHeRS) Project. “Appointments can be a costly ordeal in wages lost for a day off from work, child care, and transportation. The project is patient-centered. We basically go to them.”
In addition to telehealth services like remote ultrasound, the effort screens all participants for food insecurity. Those in need immediately receive a food package and are connected to a local food bank. All patients with diabetes or obesity also receive ongoing nutrition counseling.
Sacks highlights another key component of the program: mental health care.
“Mental health disorders carry a 50% increase in severe maternal morbidity and mortality. Nearly 9% of maternal deaths are attributable to mental health disorders. All of these figures are higher in African American patients. The situation and statistics are tragic and can fuel a worrisome intergenerational cycle.”
Looking ahead, Sacks hopes to expand the MOTHeRS Project to additional remote locations. Meanwhile, Vidant’s efforts so far have made a difference. For example, the infant mortality rate in the region dropped by 24% in recent years.
“There’s more work to be done,” says deVente. “But we set out to make this region a better place to give birth and be born, and I think we’ve succeeded in doing that.”
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Addressing maternal health inequities | AAMC
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