The Moral Healthcare Blog

Using Catalyst as Framework for Moral Healthcare Chapter 3: Distance

[These blog entries are my notes and takeaways from Jonah Berger’s amazing book, The Catalyst as I apply them to Universal Healthcare.]

The chapter starts with the example of “deep canvassing.” This involves more than just going door to door and telling people things. Rather, it involves listening to people and having deeper conversations to try to determine the roadblocks/barriers to change. While facts may be able to sway people who do not have hardened positions, contrarian facts actually harden the positions of those who already have their minds made up.

The Football Field of Beliefs.

We stand ideologically somewhere between opposing in zones of belief. The perfect moderate is at the 50 yard line. Everyone else is somewhere to the left or right. Generally people beyond the 25 yard line on either side are strongly partisan. They generally cannot be swayed. People in the middle can be swayed. It depends on the argument and depends on the issue but there is the possibility of reaching them.

Someone at midfield has a zone of acceptance of ideas on either side of midfield. The zone of acceptance shifts depending on one’s position on the field initially. There was also a zone of rejection in which ideas are too far afield to be considered. Each person’s zone may begin at a specific yard line and may vary in breadth depending on the issue. A person in the end zone may reject anything beyond their own 20 yard line.

HCR lessons: based on decades of polling, Americans are generally in favor of universal healthcare. When asked in a variety of settings about more government involvement in healthcare or outright single-payer, as in the most recent Fox News exit pulling, the favorability is strong. So most people stand to the left on the football field at least as regards universal healthcare. Until they are pounded with negative framing, fear, version, etc. Much of this message transport people to the zone of rejection very rapidly: hence the use of loaded terms like socialism, government run, government takeover and the like.

I think the good news here is that this is a lot to work with. As an issue, getting people to support healthcare for the unemployed or for the working poor or other groups that can generate empathy should be very achievable.

The Confirmation Bias.

“People search for, interpret, and favor information in a way that confirms or supports their existing beliefs.” Example here is watching a football game and interpreting penalty calls. We see what we want to see.

“Still, a man hears what he wants to hear and disregards the rest.” Paul Simon, The Boxer 1970.

“One half assed observation by me is the equivalent of 3 randomized controlled trials.” Dr. Joseph Myers, 1983.

How we combat the biases and avoid the region of rejection?

Find the Movable Middle

Example given is about changing minds during election cycle. People are at least somewhat responsive to messaging on issues, like ballot initiatives. On general election candidates? Not so much. Essentially no effect on getting people to change their votes. This dovetails with Ezra Klein’s book, Why Were Polarized. Negative partisanship is powerful and there are very few in that movable middle any longer.

The key here is to find issues on which there are moderates who are persuadable and targeting them specifically with the message-not the broader public. Persuading people that candidate is in the range of rejection on an important issue can move the needle.

Techniques: look-alike targeting, testing and learning to create data, targeting the vulnerable subgroup.

Nice to haves versus need to haves. Things that are imperative versus things that can be put off until later.

HCR lessons: Progressive legislation course requires the election of progressives. But softening the electorate to favorably predisposed him to universal healthcare will require us to move those in the middle to favoring universal healthcare. I think targeting those whom we find in look-alike groups might be fertile ground. Suburban women? Working low income people? Self identified Christians-harkening back to the Book of Matthew and the Sermon on the Mount might be useful strategies. As Berger points out, they will need to be a lot of testing and learning to create the data and then to target the suitable groups.

Ask for Less.

As simple as it sounds. Instead of asking people to support say Canadian style single-payer system, ask them if they would support expanding insurance for the unemployed for example. This can then later be parlayed into asking for a bit more and bit more.

HCR lessons: I think this is clearly the way to go. The pushback to a massive change is just to great to ignore. If by some miracle we got a wave election like Johnson got, that would be one thing, but with partisanship as it is, this may never happen again. Given that, we have to scale back our goals and focus on changing people’s minds about lesser advances.

While policy prescriptions as information drops will not change anyone’s mind, changing minds about specific issues that could get significant majority support, like insurance for the unemployed or working poor might.

Switch the Field to Find an Unsticking Point.

Deep canvassing example here regarding finding out why people were against Prop 8 in California.

“A single ten-minute “deep canvassing” conversation made voters significantly more accepting. They had more positive feelings toward transgender people and were more supportive of laws protecting them from discrimination. And the effect wasn’t just short-lived. It persisted months after the canvassers had stopped by. It even withstood exposure to attack ads from the opposition.” Deep canvassing also creates “active processing.” This occurs when the person does most of the talking and thus most of the thinking. This encourages people to find a parallel situation from their own experiences to think about.

Finding an area of agreement is called in unsticking point. It takes an abstract debate and make some more concrete discussion about love and diversity in this case. More about what it is like to be left out or judged negatively or be the victim of something or other. The discussion revolves around finding common ground to get around the sticking point. It also involves getting people to tap into their best selves.

HCR lessons: While I think individual deep canvassing can be accomplished by laypeople and may be more impactful if these individuals have truly moving stories, I think in order to move larger groups of people will take doctors and nurses. While I have no doubt one can create empathy in deep canvassing sessions and create active processing, I think at some point this will have to be accomplished on a larger scale.

I am extremely fond of and optimistic about a modern-day Kefauver Commission equivalent. The Kefauver Commission held hearings in 14 cities across the country, and more than 600 witnesses testified. Many of the hearings or broadcast on live TV and provided many with their first glimpse of organized crime in America.

Our “Healthcare in America” Commission could easily list doctors, nurses, pharmacists and other healthcare workers as well as patients victimized by the system. The American healthcare system is capable of miracles but also of base cruelty. The base cruelty is apparent to the victims, largely unknown to the upper-middle-class. Lesser cruelties, the ongoing rationing of prior authorization and high out-of-pocket expenses, on the other hand are quite well-known to the middle class. Highlighting stories of “Financial Toxicity” and America’s ruthless rationing by income should get some attention.

Further, the spotlight needs to be placed on alternatives. Conservatives love to highlight waiting times in Canada or Britain. We need to highlight the stories of the excellent healthcare in other OECD nations. We have to create recency and availability of the American horror story and also of the possibilities all around us if only were willing to learn.

“It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein.” Teddy Roosevelt.

Finally, such a commission would have to show the waste in the system. Katie Porter has begun the work of highlighting and shaming the profiteers. There are many oxen to be gored, and I believe that Elizabeth Rosenthal’s in American sickness provides a great blueprint identifying all of the malefactors. Just to be clear, I do not think these people are evil, as much as blithely going about their business trying to make a living. Maybe at the upper echelons I tend to be less magnanimous, but at least at the “working for a living” people, we just need to figure out something else for them to do. I refer you to the anthropologist David Graeber and his work on “Bullshit Jobs.”

Berger, Jonah. The Catalyst: How to Change Anyone’s Mind (p. 100). Simon & Schuster. Kindle Edition.

Using Catalyst as Framework for Moral Healthcare Chapter 4: Uncertainty

[These blog entries are my notes and takeaways from Jonah Berger’s amazing book, The Catalyst as I apply them to Universal Healthcare.]

The chapter starts with a review of Prospect Theory principles of loss or risk aversion. He develops the “uncertainty tax” concept – “When choosing between a sure thing and a risky one, the risky option has to be that much better to get chosen.” People really dislike uncertainty.

Uncertainty undermines actively making changes and can halt the decision-making process entirely. “…while uncertainty is great for the status quo, or whatever people were doing before, it’s terrible for changing minds.”

Getting People to Unpause

Trialability How easy it is to try something? In a new inexpensive consumer product like a disposable razor is easy as barriers are small to trial. New software or a new health care system? Not so easy to try.

Four key ways to reducing uncertainty are to:

Harness Freemium – Dropbox example. Free to try, makes a no-cost barrier to trial.

Reduce Upfront Costs – Zappos example. Free shipping, free returns, no uncertainty about things that are normally significant barriers.

Drive Discovery – free Acura rides at W Hotels. They created an incentive to get people into an Acura-free rides.

Make It Reversible – trial period for pet ownership from the him shelter. Reduces uncertainty because you can take the pet back. Second example is lenient return policies boosting business. While the lenient return policy can increase returns, it also removes a barrier to sales-uncertainty.

HCR Lessons: I may be not using my imagination, but I am having a hard time figuring out how to apply freemium and reducing upfront costs to our universal healthcare system issue.

I can see how giving people guided virtual tours of other nations healthcare systems could be a way to drive discovery. Would you have to pay them to do this? Or would you force them to watch it while the free Acura ride is taking place? But I do see little potential here.

Reversible might be possible. Buying into Medicare or Medicaid or public option would qualify.

Taking Advantage of Inertia

Trials take “advantage of the endowment effect by shifting peoples’ mind-set from acquisition to retention.” Once one has taken up the trial offer, they are now shifted to an owner and therefore losing the thing on trial becomes a loss. People will keep the item on trial to avoid a loss-inertia. Also worth noting that the longer people are allowed to keep something before having to return it, the more likely they are to keep it. Once you have the Zappos shoes in your home, you have to overcome inertia to return them.

Neophobia: “fear or dislike of anything new.” Identifying the particular reasons for the neophobia can help drive the strategy to overcome. Many examples given, but going vegetarian versus meatless Mondays is good one.

How can you make whatever is on offer easier for the customer?

HCR Lessons: I certainly agree that getting people into a well-functioning system would lead to the same reaction the rest of the world has about switching to an American-style system – “Are you kidding me?”

I think this is an interesting way to think about getting people to change from whatever they have two universal healthcare system:

Think about being single versus dating one person exclusively. When you’re single, you actively search for the best partner. You go on dates with different people, compare them, and consider the relative merits of each. You look for a set of desired attributes, and the list often gets longer the longer you search. This makes it less likely that anyone will ever live up to the growing laundry list, and more likely that you’ll never settle down. When you’re dating one person exclusively, however, it’s a different set of questions being considered and decisions being made. Rather than always looking for other options or wondering whether you could do better, you’re focused on the person you’re dating. As long as they are good enough, you keep dating them.

HCR Lessons: We are all dating America’s health care system and nobody has the energy to break up and find a better mate!

The case study the end of this chapter is about how a manager used uncertainty by enabling management to experience excellent personalized customer for themselves.

HCR Lessons: there somehow might be a way to have people experience the German or French system vicariously or virtually?

Berger, Jonah. The Catalyst: How to Change Anyone’s Mind (p. 169). Simon & Schuster. Kindle Edition.

Using Catalyst as Framework for Moral Healthcare Chapter 5: Corroborating Evidence

[These blog entries are my notes and takeaways from Jonah Berger’s amazing book, The Catalyst as I apply them to Universal Healthcare.]

Prime example here is of a substance abuse intervention. The corroborating evidence is supplied by the overwhelming number of attendees who are there to tell you about your problem and how it affects them. Further examples are provided about taking advice from people about cars or contractors and how corroboration from knowledgeable sources or disinterested sources increases the value of the input. The size of the decision matters also:

“How much weight, or proof, you need depends on how heavy the thing is that you’re trying to move. If you’re trying to lift a pebble, you don’t need much. Add a little evidence and it moves right away. Change happens. But if you’re trying to move a boulder, much more effort is needed. More proof is required before people will change.”

HCR Lessons: Clearly healthcare reform is a boulder. A really big boulder.

The Translation Problem

When people get recommendations, they try to translate that recommendation into what it means for them personally. Is the recommender similar? Prior recommendations? Validity of prior recommendations?

Strength in numbers. Multiple sources of information helps. It is helpful to consider which sources are most impactful, should they be spaced out over time, and how are they best deployed, especially when trying to change minds on a larger scale.

Which Sources Are Most Impactful?
1. People like me.
1. Respected people in the community.
1. People you know. Especially people you know well or with whom you have multiple connections.
1. Also people from diverse areas improve corroboration. The more independent sources are better.
1. This also goes for organizations. Substitute organizations for people in the above lines.
When?
1. Sometimes, all at once like in an intervention.
1. Closely spacing asks or invitations is more impactful.
When to Concentrate or Spread Out Scarce Resources: sprinklers or fire hoses?
1. For weak attitudes (pebbles), the sprinkler system works best. It is not as hard to move a pebble.
1. For stronger attitudes, boulders, the fire hose strategy is best.

HCR Lessons: We should be able to marshal sources in all of the ways described above. I think it is especially true that we do this with doctors and nurses. We have the stories. With some work, we may also be able to marshal organizational sources similarly. I do not think we should discount that businesses who are not profiting within the medical industrial complex are being scalped by the medical industrial complex.

Firehose: I think the Kefauver commission events would be amazing fire hoses. See my previous chapter summary about this.

Sprinkler: given the magnitude of this boulder, I think both techniques will be required in a sustained manner over a long period of time. I have been thinking a lot lately about sending ourselves in two conservative gatherings, or at least mixed gatherings like Rotary, Kiwanis and other such groups. Also on campus groups like the young Republicans and other conservative groups. Op-ed’s in traditional papers, alternative media, university media.

Again, all this is going to take a lot of resources and a lot of time and a lot of commitment.

Pebble or Boulder? How expensive, time-consuming risky or controversial is the thing?

Case study is about getting people to eat organ meats during World War II. They reduce uncertainty by providing recipes and suggesting be part of a larger family dish. To shrink distance they ask people to just try it occasionally. To reduce reactance they had small group discussions with housewives. These discussions provided corroborating evidence from similar people.

HCR Lessons: I totally agree that the campaign will have to be multipronged and this is a long game.

Berger, Jonah. The Catalyst: How to Change Anyone’s Mind (p. 181). Simon & Schuster. Kindle Edition.”

Using Catalyst as Framework for Moral Healthcare: Epilogue

[These blog entries are my notes and takeaways from Jonah Berger’s amazing book, The Catalyst as I apply them to Universal Healthcare.]

This is the case study of the Seeds of Peace group. It is a compelling story about bringing disparate people together and forcing them to live with each other and learn about each other. The changes in the participants was profound and long-lasting.

The final summary in the Epilogue:

Rather than trying to persuade people, they reduce Reactance by encouraging people to persuade themselves. Seeds of Peace has a desired destination in mind, but rather than forcing campers toward it, they allow for agency. They lay out a series of exercises and experiences that let campers pick their own paths to that outcome.

Instead of making a big ask right away, Seeds of Peace works to shrink the Distance. Rather than expecting opposing sides to be friends on day one, the camp starts by asking for less. Just sleep in the same cabin. Eat at the same table. Engage in the same activities and begin a dialogue. These activities help switch the field and find an unsticking point.

In this way, Seeds of Peace also reduces Uncertainty. Not only do they lower the up-front cost, allowing people who would normally fear one another to interact in a safe, neutral environment, they drive discovery. They don’t sit back and hope the two sides interact; they create situations where interactions happen naturally. And the fact that the camp lasts for only a few short weeks makes things reversible. Worst case, campers will be back to their regular lives soon.

Finally, by giving campers multiple interactions with different outgroup members, they provide Corroborating Evidence. Even if Habeeba and an Israeli girl become friends, it’s easy for Habeeba to see the one Israeli girl as unique. Sure, that girl is Israeli, but she’s not like those other Israelis. She’s different. And so Habeeba’s trust toward Israelis in general doesn’t really change. But when Habeeba has positive interactions with multiple Israelis, it’s harder not to shift her attitudes toward them as a group. Meaning that she’s much more likely to trust other Israelis she meets in the future.

Berger points out that we must keep asking ourselves what barriers are in the way? Keep asking how their needs might be different than ours?

Moving boulders takes years to occur. Understanding why people change and why they do not helps us understand how to remove the barriers.

REDUCE REACTANCE How can you allow for agency? Like the truth campaign, encouraging people to chart their path to your destination? Can you provide a menu? Like asking kids whether they want their broccoli or chicken first, can you use guided choices? Like Smoking Kid, is there a gap between attitudes and behavior, and if so, how can you highlight it? Rather than going straight for influence, have you started with understanding? Have you found the root? Like Greg Vecchi, built trust and use that to drive change?

EASE ENDOWMENT What is the status quo and what aspects make it attractive? Are there hidden costs of sticking with it that people might not realize? Like financial advisor Gloria Barrett, how can you surface the costs of inaction? Like Cortés, or Sam Michaels in IT, how can you burn the ships to make it clear that going back isn’t a feasible option? Like Dominic Cummings and Brexit, can you frame new things as regaining a loss?

SHRINK DISTANCE How can you avoid the confirmation bias by staying out of the region of rejection? Can you start by asking for less? Like the doctor who got the trucker to drink less soda, chunking the change and then asking for more? Who falls in the movable middle and how can you use them to help convince others? What would be a good unsticking point and how can you use it to switch the field? Like deep canvassing, by finding a dimension on which there is already common ground to bring people closer?

ALLEVIATE UNCERTAINTY How can you reduce uncertainty and get people to un-pause? Can you lower the barrier to trial? Like Dropbox, can you leverage freemium? Like Zappos, how can you reduce the up-front costs, using test drives, renting, sampling, or other approaches to make it easier for people to experience something themselves? Rather than waiting for people to come to you, can you drive discovery? Like the Acura experience, by encouraging people who didn’t know they might be interested to check it out? Can you reduce friction on the back end by making things reversible? Like Street Tails Animal Rescue did with a two-week trial period, or as others do with lenient return policies?

FIND CORROBORATING EVIDENCE Are you dealing with a pebble or a boulder? How expensive, risky, time-consuming, or controversial is the change you’re asking people to make? How can you provide more proof? Like interventionists, by making sure people hear from multiple sources saying similar things? What similar but independent sources can you call on to help provide more evidence? How can you concentrate them close in time? Making sure people hear from multiple others in a short period? For larger-scale change, should you use a fire hose or a sprinkler? Concentrate scarce resources or spread them out?

Berger, Jonah. The Catalyst: How to Change Anyone’s Mind (p. 227). Simon & Schuster. Kindle Edition.

Cognitive Science & Universal Healthcare

I recently participated in a session at Healthcare Now! 2021 Medicare For All Conference. We (USA Healthcare) put on the session called “The Way Forward for Universal Healthcare: Values Centric or Policy Centric?”

I made the Values based case, largely drawn from my understanding of the role of Cognitive Psychology on our thinking and decision-making, especially in such a values laden area of policy. I have been collecting bits of learning from here and there for quite a while and decided it was probably a good time to put something down on paper and PowerPoint and video. Here’s the result, now up on YouTube!

I hope you’ll give me feedback! Thanks, Chris

Why are conservative attacks on universal healthcare always so lame?

An Astoundingly Tone-Deaf Piece by Sally Pipes in Forbes Magazine.

“The pandemic has revealed the rotten core of single-payer.”

I can scarcely fathom a more obtuse sentence. Here we are, in America, currently competing to be a shit-hole nation, and Ms. Pipes is so clueless that she thinks the pandemic has exposed other nations’ healthcare problems. Wow. Just wow.

Data from the Kaiser Family Foundation showed the uninsured rate in America, thanks to the Affordable Care Act, had declined from around 17% to about 10%. So, as of 2018, about 27.9 million people in the US were uninsured. (For those of you who have not had the misfortune of reading Ms. Pipes work, these 27. 9 million people can’t even qualify for the horrific queues Ms. Pipes laments about.) Since the pandemic, these numbers have skyrocketed, as Mr. Trump might say. With the massive waves of unemployment due to the pandemic, Families USA estimated more than 5 million laid-off workers joined the ranks of the uninsured. They, too are not even eligible to get in the queues for care that Ms. Pipes laments.

Ms. Pipes points to the sad case of a man who died from kidney failure due to delayed elective surgeries in Canada. Sad, of course, but Ms. Pipes is no doubt aware of the saying attributed to Stalin, “A single death is a tragedy; a million deaths is a statistic” While Ms. Pipes is lamenting the Canadian system for this tragedy, the US healthcare system is guilty of the statistical heap of deaths due to kidney failure in the US. According to the CDC via the National Kidney Foundation:

Early referral to nephrology is associated with improved CKD outcomes, however Black or African American patients are more likely to have delayed referral or no nephrology referral at all. Communities of color are also overrepresented among patients with end-stage kidney disease. For every three non-Hispanics who develop kidney failure, four Hispanics develop kidney failure. Black or African Americans are three times more likely to suffer from kidney failure than Whites.

Pipes notes that three dozen people have died in Ontario due to cancelled heart surgeries. I hate to make light of this, because, you know, most Canadians care about each other and this bothers them. But in America, this is chump change, in terms of the cost in human lives. Again, More than 30 million Americans can’t even get into the queue for the cancelled heart surgeries. As Ms. Pipes probably knows, showing up in the Emergency Department actually having a heart attack does not turn out as well as having a primary care doctor you can afford to see and maybe try to avoid the heart attack in the first place. According to the American Heart Association (references omitted),

Americans with CVD risk factors who are underinsured or do not have access health insurance, have higher mortality rates and poorer blood pressure control than their adequately insured counterparts. Uninsured stroke patients also suffer from greater neurological impairments, longer hospital stays, and higher risk of death than similar patients with adequate coverage. Not having coverage or having inadequate coverage also impacts patients’ financial stability. More than 60% of all bankruptcies in 2007 were a result of illness and medical bills – more than a quarter of these bankruptcies were the result of CVD. Nearly 80% of those who filed for medical bankruptcy were insured. Additionally, uninsured and underinsured patients are more likely to report access issues related to cost, including not filling a prescription, forgoing needed specialist care, or even not seeking medical care during an acute heart attack. Delaying care can have huge negative consequences for both patients and for the healthcare system. To that extent, it is clear that not having access to quality, comprehensive health coverage and care is bad for patients.

Her next example is a woman from Nova Scotia who had to resort to a GoFundMe campaign to pay expenses for lung transplant surgery! Can you imagine? Oh, wait, about half of all money raised on GoFundMe is for medical expenses. The Guardian recently reported that “25% of Americans say they or a family member have delayed medical treatment for a serious illness due to the costs of care, and an additional 8% report delaying medical treatment for less serious illnesses.” BTW, the Guardian sites an anecdote about a woman who called in sick due to pneumonia and lost her job and her health insurance for exceeding her employer’s attendance requirements by one day.

And speaking of financial hardship, or the “financial toxicity” of disease, researchers reported in 2018, pre-pandemic, that, for Americans newly diagnosed with cancer between 2000-2012, at just year two, 42.4% had depleted their entire life’s assets, with average losses of $92,098. Only 7.9% of these were uninsured.

The overarching theme of this piece is that somehow citizens with universal and affordable access to care are paying a steeper price than those of us with an unreliable and expensive healthcare infrastructure. She gives examples of people with access to universal, affordable healthcare are now caught in a backlog due to the pandemic. That is awful. But, the idea that America is somehow immune to the disruptions necessitated by COVID-19 is so ludicrous that I don’t think it needs dignified with a reference. If the planet you are living on has not allowed in enough oxygen to allow you to not see what utter nonsense this is, then you stopped reading this a long time ago!

This wouldn’t be a Sally Pipes piece without a partisan attack, and she does not disappoint, attacking Joe Biden and Democrats for working towards universal healthcare. She closes with this precious line, “The pandemic has revealed the rotten core of single-payer.” I have been saying for some time now that avarice and amorality are the rotten core of American Healthcare, and the pandemic has, as possibly it’s only upside, exposed the truism that American healthcare is a mess.

Cognitive Science Lessons.

People like Ms. Pipes have spent decades making sure that stories like the ones she has in her articles are pushed front and center in people minds. It is very effective in insuring predisposition to opposing healthcare reform for the following reasons:

Recency Effect and Availability Bias. Placing narratives, especially emotionally charged ones, as Pipes’ does expertly, is a powerful tool. It activates our mind in several ways. Because we hear stories like these repeated by conservatives over and over again (mostly the same set of stories), they are both recent and available, and thus come to mind when we are asked to think about universal healthcare. When there is a discussion of the topic, these types of anecdotes come to mind and reinforce opposition, if that is our predisposition, to change. The obvious counter to this is to make the “American Horror Stories” that physicians, nurses and really anyone who has had an interaction with the healthcare system, know so well, and tell those thousands and millions of stories! Even for someone who has run the gauntlet and gotten the crowning jewels of medicine, like a transplant or interventional procedures or survived sepsis in the ICU, it is rare to not have numerous tales of the hassles of prior authorization and “explanation of benefits” forms and bills and checks and everything that makes the business of medicine such a horror show.
Loss or Risk or Dread Aversion. Knowing or hearing stories of dreadful outcomes creates powerful aversion in us. If we hear stories of people not receiving care and dying, that arouses significant emotions and colors our assessment of a problem. Thus, when stories are recent, available to our minds readily and scary, they are impactful. And as with the former effects, those who know the benefits of universal healthcare that we see around the world, and the horror show we see here in America, this should be our wheelhouse. We have the stories of the heartlessness and cruel rationing of care in front of us every day. We need to collect them and use them. Recency, availability and dread aversion need to become the friends of advocates for universal healthcare.
I was going to add a third point here about the pro-business, pro-corporate brainwashing that has occurred in the US over the past half century or so, but rather, I’ll just ask you to read Anand Giridharadas’ Winners Take All, or at least get a taste of it here in this Guardian review. And for those who think private corporations always handle things better than government or other public agencies, I’ll just ask you to recall the last time you called your a) cable company b) health insurance company or c) well, almost any large corporation.

Winning over the disaffected to Universal Healthcare #UHC

Someone who clearly knows how I think sent me this article – The Facts Just Aren’t Getting Through today from The Atlantic. Thanks to Anne Applebaum for some great ideas!

If you read it through my eyes, always looking for ways to convert others to the Universal Healthcare (#UHC) Team, several things stand out:

The appeal to patriotism: UHC should be indivisible with patriotism of the best kind!
- A friend of mine is very fond of Danielle Allen’s book, Our Declaration: A Reading of the Declaration of Independence in Defense of Equality and wants to use its themes for UHC advocacy: It is a progressive re-reading of the Declaration of Independence, emphasizing the true meanings of freedom and equality.
- We the People: A Progressive Reading of the Constitution for the Twenty-First Century by Chemerinsky inspires similar patriotism in a progressive vein.

The Republican Voters against Trump ads use members of their own tribe to express disillusion.
- There are many disillusioned members of the Medical Industrial Complex.
- We need to start identifying them in preparation for a UHC campaign using their insights.
- Like Wendell Potter, they can provide perspective for the currently trapped.
There is value in helping the disaffected realize that they can find community among others who believe like them, even as they separate from another ideological community.
- “You won’t be left alone!”
- There are many others like you disillusioned and angry at a system that mistreats so many of our fellow citizens.
- Leaving a community that believes that the suffering and dying of our disadvantaged is just part of the “American Way,” should be easy. They just need a new community. Us.
Humor melts fear.
- Having been an intensivist most of my career and then a hospice doc, I can tell you that medical humor can be very dark.
- We in the medical community might need some guidance in channeling our humor in a more gentle way…

We’re not ready for Single Payer Healthcare (because we disagree on basic morality)*

“A common incantation during debates on health reform… is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”

– Uwe Reinhardt

In a 2011 Republican Presidential debate, candidate Ron Paul was asked a pointed question about what to do with someone who needed expensive healthcare but did not have insurance: “Are you saying that society should just let him die?” Some in the crowd jeered “Yeah!” Paul indicated that as a physician, he did not find it acceptable to do so and offered charitable care from “churches” based on his experience of practicing medicine in the in the early 1960s, before Medicare and Medicaid, eliciting applause from the crowd.

Last year, I attended the Keystone Progress Conference in Pittsburgh, PA for a few hours. I attended a panel discussion of progressive candidates who lost their elections in deep red districts. One of the things I heard was straight out of this Ron Paul universe – all four of these candidates said they were surprised that so many of the conservative voters were afraid, of having others “get over on them.” That these others would get free healthcare and they were going to have to pay for it, for “those people” to be freeloaders that they would have to subsidize, etc.

In 2013, Dan Munro, writing for Forbes magazine, on the anniversary of Martin Luther King, Jr.’s “I have a Dream” speech, pointed to several myths so common to conservative thought about America, in particular our backwards interpretation of the “bootstraps” fable:

“the myth that literally anyone – through hard work and determination – can rise out of any poverty and become rich and prosperous. We salute, praise and deify everyone who does. But there’s a dark side to this myth. Anyone who doesn’t isn’t working hard enough – or doesn’t have enough determination. In effect, they’re a loser – and nobody wants to pay for the healthcare of those losers.”

Veronica Combs paraphrased it as ”There is a real meanness in the conversation about who should have healthcare, an implication that people who need help somehow don’t deserve it, or that they are taking advantage of ‘the rest of us.’”

All of this, of course, is not really news. Making a moral case for universal health care in any form is denounced as socialism or “not the job of government,” or as Ron Paul said, that we must “assume responsibility for ourselves.” The American Medical Association has famously opposed movement towards universal healthcare, from the Truman Administration to the passage of Medicare and Medicaid and through opposition to major parts of the Affordable Care Act.

Martin Luther King, Jr., noted that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” Many have railed about the inhumanity of Americans towards each other regarding healthcare, and the late Professor Uwe Reinhardt has asked for decades, “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in healthcare?” Americans, capable of unbridled generosity in helping individuals pay for a transplant or some other services when the individual in question is deserving, are ruthlessly coldhearted when compassion is requested for those they deem undeserving, as the Tea Party crowd showed us in 2011.

Reinhardt was clearly stung by the idea that his adopted countrymen (he was German born US citizen) rejected this solidarity, in contrast to every other nation’s resounding “yes” to the question. He also pointed out that the way Americans avoid the moral question that faces us is to play the game framed by the introductory quote: we pretend that the problem is that we disagree on policy, writ small and large, and find ourselves down rabbit holes about the reimbursement for an anesthesiologist for a fifteen minute unit of time with or without a nurse anesthetist!

Every other nation has started with the moral and ethical question over their values as a society and worked towards a solution to provide healthcare to all their people, “deserving” or not. As another professor noted:

“The last time I taught in the Semester at Sea program, I found it necessary to interpret for our students the rich “social capital” that runs through the Northern European societies we were visiting. What they knew and had read in their guide books was that not many people are in church on Sunday morning, especially compared to the florid religiosity of the United States. So their working assumption was that Americans take religion seriously and Europeans don’t. The new thought that amazed them was that the unchurched Europeans live in social democracies deeply saturated with historic Christian values, while the much-churched Americans celebrate a society characterized by a ruthless social Darwinism that the God of the Bible, Old and New Testament alike, denounces.”

What is preventing us from having the basic moral argument about our values regarding health care? The answer is three-fold. The first is a strong puritanical streak in American culture that prompts many of us to divide our fellow citizens into camps of deserving and undeserving people. The second is a now unfathomably large industry that has much to lose should efficiency and order find their way into the American Healthcare system. The third is our human cognitive biases that lead us to sloppily assume political and moral positions that will take years of work to overcome, using cognitive psychology to reframe the debate and convince people that doing the right thing is the right thing to do — for everyone.

Three Books: A Summary of a Doctors for America Session held at the National Leadership Conference

Three Books: A Summary of a Doctors for America Session held at the National Leadership Conference on November 9, 2019

I recently did a workshop session at the Doctors for America National Leadership Conference in Baltimore. The session was titled Prospect Theory, Medical Industrial Complex and Social Justice in Health Care: 3 Important Books. I have recently had the opportunity to be able to devote some time to thinking about healthcare reform in general, and the distressing lack of progress toward universal healthcare in America spanning my entire career and beyond.

I came across the late Uwe Reinhardt’s last book, Priced Out, which was a summary of his life’s work: the ludicrousness of “America’s Healthcare Wonderland,” as he calls it, and the ineffectiveness of any moral arguments to persuade the American political class to move towards universal healthcare. I had the opportunity to exchange a few emails with Prof. Reinhardt about 5 years ago. At that time, he seemed quite pessimistic about the opportunity of America moving forward. In his book, however, his life partner, Prof. Cheng, in her epilogue, makes it clear that he remained optimistic about America’s chances for universal healthcare. He thought, she said, that we would probably stumble towards it and not actually make a cultural or societal decision, but that we would eventually get there in fits and starts.

Prof. Reinhardt’s chief concern is that we never have the moral discussion required to propel us towards a universal healthcare ethic. Without the ethic, he argues, there can be no successful transition to a universal system. He has said that during healthcare debates, we have an incantation, “’we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”

He is right. We do not agree. We agree on the left that universal healthcare is an imperative, and those on the right agree that healthcare is a market commodity and should be treated like any other good or service. Of course, progress is made by convincing enough people in the middle that one’s policy proposals or political arguments are worthy of implementation. One need not win over everyone. Medicare, Social Security, civil rights, and so much of America’s progress in the past century was not unanimous. Given the opportunity, many conservatives would still reverse the New Deal, the Great Society, and of course, the Affordable Care Act.

Progressives have failed to win the moral and political arguments in favor of universal healthcare. As Wendell Potter has pointed out, the methodology of the entrenched and well-funded interests opposing progress are simple: fear, uncertainty, and doubt. Simple and devastatingly effective.

The Undoing Project: A Friendship That Changed Our Minds by Michael Lewis holds many of the answers as to why it is so effective. The book tells the story of the two psychologists who developed Prospect Theory. Prospect Theory was the basis of what we now call behavioral economics. It is the exploration of why we make the decisions we make. It is about why we make the irrational decisions that we make.

Briefly, our brains are fooled in a variety of manners. We have fast, intuitive thinking. This thinking is swayed by a variety of biases. Gains and losses are perceived from specific reference points. The fear of loss, risk aversion, is far more powerful than the lure of gain. Things that come to our mind easily, either through recency or frequency (availability) greatly impact our decision-making. The fast, intuitive mind is influenced heavily by these biases. And unfortunately, the fast, intuitive mind is very confident.

Our more logical, slow thinking brain is analytic. It is also unsure of itself because of its self-critical analysis. That is why a plausible and emotionally resonant feeling, as Mark Twain might say, is halfway around the world before a detailed policy proposal gets its pants on. Or, as Stephen Colbert might say, truthiness works.

There are many lessons to be gained from Prospect Theory, but the key insight from Daniel Kahneman is that “We don’t choose between things, we choose between descriptions of things.”

After reading The Undoing Project I was somewhat optimistic and excited about the possibility of using some of these techniques to combat the campaign of fear and uncertainty and doubt that is awaiting us as we march into an election year with healthcare reform as a major point of contention.

Unfortunately, I then read An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, by Elisabeth Rosenthal. Dr. Rosenthal provides a discouragingly comprehensive evaluation of the medical industrial complex and how it has come to dominate every aspect of the provision of healthcare. The chapters catalog the breadth: health insurance plans, hospitals, physicians, the pharmaceutical industry, the medical device industry, testing, laboratory, and all other manner of ancillary services, contractors, billers, coders, collections agency, researchers, not-for-profit organizations, and of course the rise of the massive healthcare conglomerates, euphemistically known as “integrated delivery systems.”

As Don Berwick recently wrote, there is $1 trillion of waste in the healthcare system. And one man’s waste is another man’s revenue. Dr. Rosenthal details all that waste and in doing so, lays down the markers on the battlefield. One side is well-funded and is fighting for its very existence. Or at least fighting for the very upscale version of its current existence, and desperate to avoid a comparatively spartan OECD-like existence.

As Upton Sinclair once said, “It is difficult to get a man to understand something if his livelihood depends upon his not understanding it.” As Wendell Potter more recently said, “Health insurers have been successful at two things, making money and getting the American people to believe they’re essential.”

I finished my remarks, and opened up the floor for discussion. We spent a fair amount of time reviewing the concepts above. I specifically asked for help in developing framing and arguments that might help us in our advocacy work. Several themes emerged, and I have highlighted them here.

1. Talk about the moral case for health care. We discussed the deserving-undeserving framing, the puritanical streak in American politics, and the fear of others “getting over on us.” I told the story of having gone to a progressive conference after the 2018 election. I had the opportunity to hear from four progressive candidates who lost their races in conservative districts. All four of these candidates said they were surprised that so many of the conservative voters were afraid, almost exactly as I had phrased it to you, of having others ‘get over on them.” That these others would get free healthcare when they were going to have to pay for it, for “those people” to be freeloaders that they would have to subsidize, etc.

2. Talk about work arounds and hassles. I pointed out that the second half of Dr. Rosenthal’s book was a guide for those who are trying to deal with the Wonderland of American healthcare. While quite useful in the here and now, it amounts to a series of workarounds of the system as it exists. Useful, to be sure, but it is not a prescription for ending the need for workarounds. As Teresa Brown recently put it in a New York Times piece, American healthcare system is one giant workaround.

3. Talk about student debt, medical school tuition and physician income. We had a discussion about the rabbit holes, as I call them, of excruciatingly detailed policy points surrounding any healthcare reform. As Uwe notes, whenever this happens, we then engage in protracted and useless arguments over the value of quarter hour of an anesthesiologist time, or other some such parochial detail of concern. It was pointed out that these concerns arise out of the value of medical school education and residency training, the heady medical school costs and student debt, as well as physician income. The group argued to take these issues head-on. Have a discussion about subsidizing medical school and have a discussion about the relative value of the various specialties. Have a discussion about work hours and on-call time, medical liability, and the many other practical issues moving towards universal healthcare system.

4. Talk about price control and administrative simplification. There is no love lost between physicians and the rest of the healthcare industry. There is also no love lost between consumers of healthcare services and the healthcare industry. The group felt that it was well worthwhile to point to alternative methods of controlling costs in the healthcare system. We discussed Prof. Reinhardt’s maxim that “It’s the prices, stupid!” We discussed the unconscionable waste of time and money spent dealing with health plans, from in-hospital utilization management to outpatient prior authorization for everything from procedures to medicines to wheelchairs. These issues potentially put us on the same side with the public and politicians.

While driving home from the conference, I began listening to Daniel Ariely’s Predictably Irrational. Prof. Ariely spends a significant amount of time discussing the difference between market norms and social norms. The way we behave around wages, prices, rents, and other payments are our market norms. The way we behave around doing each other favors, helping one another and other activities that do not involve financial exchanges, are our social norms. He provides many examples showing that things one might do unhesitatingly under the structure of social norms, are out of bounds under market norms. For example, lawyers asked to do work for a nonprofit company at a very low rate reject the proposal. Lawyers asked to do pro bono work readily agree. Injecting finance into a situation that normally operates on social norms profoundly alters the perception.

It occurs to me that this is at the center of Prof. Reinhardt’s assertion in his book. We will endlessly and vociferously debate on the number of and reimbursement for, angels dancing on the head of a pin, and always avoid the underlying discussion of whether we, as Americans should be the keepers of our less fortunate brothers and sisters for their healthcare needs.