Author: cmh

Notes and thoughts: Thinking fast and slow about universal healthcare.

Thinking fast and slow about universal healthcare.
I have been thinking about healthcare reform in general and universal healthcare in particular, for decades now. I am well aware of the admonition of Uwe Reinhardt that, in healthcare reform, everybody’s 2ndchoice is the status quo, and thus reform is hard-fought. But, because of an excellent book by Michael Lewis, The Undoing Project, about the world changing work of Daniel Kahneman and Amos Tversky, and Daniel Kahneman’s own book, Thinking Fast and Slow, I have been able see more clearly why healthcare reform is so damned difficult.
The major concepts explored in Tversky and Kahneman’s seminal work on Prospect Theory and in Kahneman’s book explain the failure of healthcare reform in America better than nearly anything I have explored before. The only caveat I will add to this is that as the late Uwe Reinhardt pointed out, Americans have also steadfastly refused to have the moral argument about whether or not we should even strive for universal healthcare, let alone how we should get there! “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.”
Thinking is divided into fast and slow subsets. System 1 thinking is fast and intuitive. It is also confident. Overly confident, according to Kahneman. System 2 thinking is slow and deliberate. It is more difficult, it takes more time, it is less confident.
System 1 thinking leads many to believe that any changes to the US healthcare system that would make it more like any other nations healthcare systems would be bad. This thinking occurs with minimal or no actual reference data, other than what it picks up from its favorite news sources. If the person has seen a story or two about waiting times in Canada, or a patient not getting timely care in the UK, system 1 confidently trashes any talk of change. The medical analogy, as taught to me during my medical school days is, “One half-assed observation by me is equivalent to 3 randomized controlled trials.”
Kahneman uses the following example: a bat and ball together cost $1.10.
The bat costs a dollar more than the ball.
How much does the ball cost?
People intuit what is an incorrect answer, 10 cents, and confidently do so, because they did not check. The answer is easy, but System 1 intuition confidently plows ahead with the incorrect answer.
Politicians, pharmaceutical and health insurance industries as well as the many support industries around them, promote this thinking, in a constant multimedia barrage, reinforcing false intuitions.
System 2 thinking is less confident and more deliberative. It takes longer. It requires more effort. It requires a commitment. Thus, it too often takes a backseat to our intuitive thinking.
All of our thinking is subject to the other forces outlined in prospect theory, namely, reference points, loss aversion, framing, availability, and the sunk cost fallacy.
In classical economic Utility Theory, the dollar is a dollar. $5 million should make us happy. But if I start with $1 million and my friend starts with $9 million, and we both end up with $5 million, I am much happier than he is. Reference points and starting positions matter.
Consider the healthcare analogy. I have a “Cadillac health plan.” You have no health insurance. Health care reform is proposed that will give us all excellent health care coverage, covering virtually every medically necessary expense we can have with minimal out-of-pocket expenses. If this passes, from my perspective, I have lost the best of all possible worlds even though the new coverage is essentially the same world. You are happy. I am not.
Most of us are familiar with the concept of loss aversion. Since being introduced by Kahneman and Tversky, the concept has seeped into the collective consciousness. Simply stated, we feel the pain of loss much more deeply than the happiness of gain. If I offer 2 tickets, one with a guaranteed win of $500 and one with a 50/50 chance of winning $1000 or nothing, most will choose the guaranteed win. If I offer 2 tickets, one with a guaranteed loss of $500 and one with a 50/50 chance of losing $1000 or no loss, most people will take the chance to avoid the guaranteed loss of $500.
If I offer to flip a coin with you, and heads you win $1000 and tails you pay me $1000, you will not take that bet. Our loss aversion is so high, that it requires winning about $2000 to overcome the loss aversion.
If I have Cadillac health plan, or even a standard employer-based plant, I am so concerned that changing to a universal plan will result in some kind of loss to me, I am inclined to fight vigorously to avoid that chance. Here again, proponents of the status quo will foment fear, uncertainty, and doubt. Fear, uncertainty, and doubt amplify the fear of loss and the resistance to change.
We have all become familiar the consequences of framing the argument. If, as a physician, I tell you that your chances of dying from treatment I am recommending is 10%, there is a decent chance will decline to treat. On the other, I tell you that this exact same treatment as a 90% chance of success and survival, there is a significantly greater chance that you will agree to it.
In universal healthcare debate, negatively framing the possible consequences of change are exploited ruthlessly. If I tell you that changing our health system will result in you losing the employer-based health insurance plan that you have come to depend on, you will almost certainly reject it.
If I tell you that transitioning to a universal healthcare system will result in a more comprehensive coverage plan, less of your wages going to your healthcare coverage and more going directly to you as increase wages, a vast reduction in co-pays and out-of-pocket expenses, and that you never have to worry about losing your coverage, whether or not you are too sick to stay in a job or your job for our opportunities, likely I can convince you that this is a good thing.
Alternatively, if I tell you that we will be transitioning to a system, modeled on the Canadian system or British system, and the only things you know about those systems are what you have been told in the media, relentlessly, for decades, the uncertainty and potential loss to you and your family become so overwhelming that you cannot possibly imagine accepting this option.
This dovetails with the concept of availability. If we are asked to guess how many words in the dictionary start with “R” versus have “R” in the 3rd position, we will guess a far higher number of the former than the latter. This is because we can think of lots of words that begin with “R” very rapidly – they are “available” to us – and so we overestimate the number of words beginning with it. Similarly, if the stories that come to mind rapidly about alternative healthcare systems are of long waiting times and forgoing treatments, our minds naturally fixate on these examples. As someone who spent the last 15 years or so studying international healthcare systems, my mind rapidly goes in the opposite direction, with myriad examples of better access to care, lower costs, and so on that anchor my thinking to the benefits of other systems, rather than the potential downsides.
Finally, the sunk cost fallacy is a bit harder to envision in the universal healthcare debates, as it is well camouflaged. As a nation, we have contributed trillions of dollars to the building up of massive companies, both for-profit and nonprofit like, presuming that this investment is giving us the best possible health care system. It is not. This is not to say that our institutions are failing, quite the contrary. We have the best trained healthcare professionals in the world. We have the best medical research in the world. We have many of the best hospitals in the world. But our para-medical companies are not serving us well. They have created bloated, imperious, rapacious engines of profit, paying lip service to the primacy of patients or members or participants or providers, but legitimately only excelling at growth.
When we think of the scale of the infrastructure surrounding the administration of health insurance plans, pharmaceutical manufacturers, medical device makers, and the related supporting industries, the footprint in the economy is massive. The workforce is massive. In health plans alone there are armies of nurses and doctors and support staff and administrators supporting them, whose sole task is called “utilization management,” what the rest of the world knows as the “approval/denial people.” In the trenches of the opposing armies, are their counterpart nurses and doctors and support staff and administrators working for hospitals or clinics or doctors’ offices, engaged in daily battle over whether the member/patient is “eligible” for the treatment or payment being sought.
Wendell Potter has pointed out that, “Health insurers have been successful at two things: Making money and getting the American public to believe they’re essential.” They will not go quietly into that good night. There is too much money on the line. Never mind that most of it adds no value to the health care system (i.e., it is waste), it is a robustly reliable revenue stream.
“One man’s waste is another man’s revenue.”
Well, that is all very grim. What is the solution?
My proposal is to use both system 1 and system 2 thinking to show the clear advantages of transitioning to a universal healthcare system in America. I am not talking about “gaming” the American psyche, I am talking about de-programming it from decades of misinformation propagated by the special interests that continue to literally and figuratively make a killing off of healthcare in America.
Continued in part 2. (When I get to it!)
Recommended reading:
Lewis, M. (2016). The undoing project: A friendship that changed the world. Penguin UK.
Rosenthal, E. (2018). An American Sickness: How Health Care Became Big Business and How You Can Take It Back. Missouri Medicine, 115(2), 128.
Reinhardt, U. E. (2019). Priced Out: The Economic and Ethical Costs of American Health Care. Princeton University Press.

Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD

Priced Out
The Economic and Ethical Costs of American Health Care
by Uwe E. Reinhardt
Epilogue by Tsung-Mei Cheng
Forewords by Paul Krugman & Sen. William H. Frist
Reviewed by Christopher M. Hughes, MD
If you are a novice to the subject of health care policy, the first few chapters of Priced Out will leave you dumbfounded at the absolute mess we have made of healthcare in the United States. Professor Reinhardt calls it a “wonderland,” and not in the pleasant sense. The wonderland is the morass of payment schemes that allow a multitude of administrators (insurers, pharmacy benefits managers, etc.) to skim just a few cents off each health care dollar spent before the remainder makes its way to those actually providing services to patients. Example after example highlight the mess we have created at the altar of “the market” or “competition” or the illusion of “choice.”
If you are in the morass, as a physician or nurse or student of health policy, you will sigh in recognition of the things you may have already known, but you will see more clearly with Prof. Reinhardt’s great ability to make the complex comprehensible. For example, the highly “popular” Health Savings Accounts, are known to be a sop to high income households, especially healthy households, but Uwe points out that they have also sprouted a cottage industry of administering these accounts, taking just a little “haircut,” as he likes to say, of the billions of dollars that flow through their accounts each year.
For me, as someone in the morass as a physician, a physician currently working in the health insurance industry and someone who teaches health policy, I was aware of most of the accretions and detritus that make our health delivery system a mess, but Uwe always manages to add this kind of level of detail to, well, just infuriate me! Other examples are the “categories” of human beings we have in the US, from the poor to the near poor to the wealthy, to those covered by Medicare or Medicaid or both or neither or those covered by employer-based insurance to those in the Affordable Care Act Marketplace – or not. He jokes that in most nations, there is only one category of human beings. We have made micro-categories a high art.
Chapters on the outrageously complex mechanisms we use to price services and how we pay the bills are head slapping. Even as one in the middle of the morass, I am still shocked to see the insane specifics of how we have passively allowed this all to go on under the banner of “competition” and “market freedom” and other euphemisms for greed. Convoluted methodologies to “control costs” by external administrative mechanisms rather than evidence-based practice infuriate physicians and have spawned the multitude of staff in doctor’s offices and hospitals to obtain “prior authorization” to prescribe medications or perform surgeries or even to determine if one is sick enough to be in the hospital.
The second half of the book focusses on the social ethic of our health care system. Uwe states it plainly: “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in healthcare?”
This is clearly more troubling to Uwe than the economics or health care and how deranged our system has become. After the failure of the Clinton Health Plan in the 90’s, he wrote a powerful article in the Journal of the American Medical Association (JAMA) called, Wanted: A Clearly Articulated Social Ethic for American Health Care. In it, he asked the precursor to the above question: “should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?” He was clearly stung by the idea that his adopted countrymen rejected this solidarity, in contrast to every other nation’s resounding “yes” to the question.
He explains that our tendency in American political life is to pretend that our disagreements on health care are due to the details and howto get to universal health care. So rather than have the broader ethical discourse that could answer the two extremely important questions he has posed, we camouflage and misdirect and devolve our discussions to the best way to bring market forces to bear or how to properly fund Medicaid in the states. We never answer the basic question of whether we should strive for universal healthcare.
He has said elsewhere, “A common incantation during debates on health reform, for example, is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”
He spends a significant section of the book exploring his framing for this fundamental disagreement among conservatives and liberal. But he does not have an answer for us on how to get where he clearly wants us to go – as explicitly stated by his widow, TM Cheng in her epilogue – “he passionately believed in universal healthcare.”
In an exchange I had with him a few years ago, he wrote, “the problem in America is that the elite does not share a consensus on what the social ethic governing American health care should be. I am not sure it ever will reach such a consensus.”
In the epilogue by Dr. Cheng, she documents his hopes and thoughts and, surprising to me, his optimism in America. We would hobble along, he thought, and continue to figure things out as we went, and perhaps technology can improve our lot.
The book left me less optimistic about our chances to reach consensus, but more committed to trying to make it so. Profs. Reinhardt and Cheng spent decades trying to advance American healthcare and continually try to engage on the ultimate questions of our social ethic, paraphrased by Michael Moore in Sicko as, “Are we about me, or we?”
The glimmer of hope I still have rests on two foundations. Uwe’s clear-eyed articulation of the questions we have before us and their obvious answers and my faith in the doctors and nurses who provide healthcare in the trenches, as we like to say, and who have long ago had enough.
In 2002, “Medical Professionalism in the New Millennium: A Physician Charter,” was published as a Project of the ABIM Foundation, the ACP–ASIM Foundation, and the European Federation of Internal Medicine. In the Charter are calls around the Principle of social justice, Commitment to improving access to care, and Commitment to a just distribution of finite resources. It specifically charged the medical profession to “promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”
The Charter argues that “Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.”
This Charter has been endorsed by virtually every group within organized medicine, from the American Medical Association to the American Board of Radiology to the American Nurses Association. While it is not explicitly a call for universal healthcare in America, it is hard to view the principles and not see this as the logical conclusion. And in fact, at the time of its publication, there were quite a few dissenting commentators who saw it as just that, and so rejected it.
I am taking Prof. Reinhardt’s last book as the plainspoken economic and practical case to shake ourselves free from this embarrassment of a “system” we have watched become a more hideous monster than we ever contemplated. I am also taking it as the simple moral argument for whywe need to change. We must stop allowing ourselves to be pulled into discussions about what flavor of health care reform we like best, and have that knock-down, drag-out fight about who we are as a nation. Are we the nation that cheers when one of us gets struck by a car and is left to die because they chose to forego health insurance? Or are we the nation that sees ourselves in the suffering of others and wants to help?

In Texas Hospitals, You Don’t Get to Decide to End Care | Houston Press

In Texas Hospitals, You Don’t Get to Decide to End Care | Houston Press: 2016

[Full disclosure – I don’t know if this has been changed at this time.]

“In Texas it doesn’t matter what instructions you’ve previously given or what your relatives say: If you’re in critical condition, you’re dependent on machines to survive and hospital officials decide it’s time to pull the plug, you will die. And it’s completely legal.”

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Pharmaceutical corporations need to stop free-riding on publicly-funded research | TheHill

Pharmaceutical corporations need to stop free-riding on publicly-funded research | TheHill: “The White House’s report suggests that it costs an estimated $2.6 billion to develop a new drug today, though they’re basing this on a single, non-transparent pharmaceutical industry-supported study with problematic methodology.

In reality, companies receive substantial publicly-funded support from the government. A recent study found that all 210 drugs approved in the U.S. between 2010 and 2016 benefitted from publicly-funded research, either directly or indirectly.

Taxpayers contribute through public university research, grants, subsidies, and other incentives. This means people are often paying twice for their medicines: through their tax dollars and at the pharmacy.

At Doctors Without Borders/Médecins Sans Frontières (MSF), we see each and every day the human suffering caused in the places we work and many countries outside the U.S. by treatments being rationed or people being denied essential medical care due to high drug and vaccines prices.”

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Why conservatives are so obsessed with guns.

Why conservatives are so obsessed with guns.:

“A more workable psychological explanation begins by noting that psychologists have found consistent differences between conservatives and liberals in personality traits, attitudes, and moral stances. To summarize some of the research findings, conservatives tend to be more likely than liberals to accept or even embrace authority that is perceived to be legitimate. Conservatives tend to be more moralistic and more conventional than liberals. They tend to have a stronger need for order and control and stability and a greater dislike of change.

“Conservatives also tend to value equality less than liberals. They have less empathy and are more likely to see human nature as bad. Compared with liberals, their moral sense is less centered on fairness and kindness and more on loyalty, deference to authority, and moral and sexual purity. Conservatives also show a greater tendency than liberals toward dichotomous thinking and have a stronger need for certainty and cognitive consistency. (“I don’t do nuance,” George W. Bush famously told Joe Biden. )

“The differences are not universal, of course, and there is nothing intrinsically bad or intrinsically good in the characteristics typical of either camp. But conservatives tend to lean one way, liberals the other.

” And some of these differences appear to be directly expressed in divergent beliefs relevant to the gun control debate. For example…

“…But it is hard for conservatives to accept these arguments. The interaction between characteristic conservative personality patterns and universally shared patterns of cognitionleads to conservatives being disproportionately skeptical of evidence provided by “experts” and scholarly studies. So conservatives turn to other means to soothe their anxiety. Some project their own anger onto others, fantasizing that people of color, immigrants, and feminists are the cause of their own inner torments. Anger, if nothing else, makes them feel bigger and more powerful.”

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Some Americans spend billions to get teeth whiter. Some wait in line to get them pulled. | The Washington Post

Some Americans spend billions to get teeth whiter. Some wait in line to get them pulled. | The Washington Post:

As the distance between rich and poor grows in the United States, few consequences are so overlooked as the humiliating divide in dental care. High-end cosmetic dentistry is soaring, and better-off Americans spend well over $1 billion each year just to make their teeth a few shades whiter.
Millions of others rely on charity clinics and hospital emergency rooms to treat painful and neglected teeth. Unable to afford expensive root canals and crowns, many simply have them pulled. Nearly 1 in 5 Americans older than 65 do not have a single real tooth left.

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Long Waits for Doctors’ Appointments Have Become the Norm – The New York Times

Long Waits for Doctors’ Appointments Have Become the Norm – The New York Times: “The Commonwealth Fund, a New York-based foundation that focuses on health care, compared wait times in the United States to those in 10 other countries last year. “We were smug and we had the impression that the United States had no wait times — but it turns out that’s not true,” said Robin Osborn, a researcher for the foundation. “It’s the primary care where we’re really behind, with many people waiting six days or more” to get an appointment when they were “sick or needed care.”

The study found that 26 percent of 2,002 American adults surveyed said they waited six days or more for appointments, better only than Canada (33 percent) and Norway (28 percent), and much worse than in other countries with national health systems like the Netherlands (14 percent) or Britain (16 percent). When it came to appointments with specialists, patients in Britain and Switzerland reported shorter waits than those in the United States, but the United States did rank better than the other eight countries.

So it turns out that America has its own waiting problem. But we tend to wait for different types of medical interventions. And that is mainly a result of payment incentives, experts say.”

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