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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.

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 2^ndchoice 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 3^rd 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!)