Prospect Theory – The Moral Healthcare Blog

Using Catalyst as framework for Moral Healthcare Chapter 2: Endowment

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

Endowment (Wikipedia): people are more likely to retain an object they own than acquire that same object when they do not own it; or, “an application of prospect theory positing that loss aversion associated with ownership explains observed exchange asymmetries.” ( Zeiler, Kathryn (2007-01-01). “Exchange Asymmetries Incorrectly Interpreted as Evidence of Endowment Effect Theory and Prospect Theory?”. American Economic Review. 97 (4): 1449–1466. doi:10.1257/aer.97.4.1449. S2CID 16803164.)

Kahneman and Tversky did an experiment with Duke students who were competing for NCAA playoff tickets, some got them, most did not. When asked to value the tickets, those who had them placed a massive value on them, while those who did not have them expressed a fractional willingness to pay.

Same with homeowners – they value their home far more than strangers who are looking to buy.

Status quo bias: Our natural tendency to prefer things as they are.

“Whenever people think about changing, they compare things to their current state. The status quo. And if the potential gains barely outweigh the potential losses, they don’t budge. To get people to change, the advantages have to be at least twice as good as the disadvantages.”

Uwe Reinhardt’s observation is that everyone’s second choice in any healthcare reform scheme is the status quo, so it almost always wins.

Loss Aversion: The classic example is again K&T of the coin flip bet. We are uninterested in gambling with a significant potential loss. We are very interested when the loss is the given unless we gamble. The factor for the former is $260 – $100.

How to overcome Endowment Effects?

Surface the Cost of Inaction

“When the status quo is terrible, it’s easy to get people to switch. They’re willing to change because inertia isn’t a viable option.”

Email signature example: You have to demonstrate the cost (time) is greater doing nothing (status quo) in the long run.

Investment example: Safe investing costs money in the long run. Show the cost of the status quo.

The cost-benefit timing gap. This is essentially delayed gratification. If there are upfront costs in time, money, effort, to achieve a benefit, inertia will likely prevent action.

“But while doing nothing often seems costless, it’s often not as costless as it seems.”

HCR Lessons:

What is the cost of an action in healthcare in the United States?

I think the obvious answer here for those who are currently covered by employer-based insurance or Medicare is the financial cost is not going to be sustainable. Making the argument that it already is unsustainable is pretty easy, too! The ongoing theft of wages by the medical industrial complex is both quiet and brazen. Seniors have a fear of losing Medicare. The biggest threat to Medicare is the rapidly increasing costs and the eventual unwillingness country to continue paying for it.

The next answer is the economic loss. We can pull up all the figures off losses to the economy due to illness and lack of access to treatment. We can cite loss of opportunity and loss of human capital potential due to our current predicament. There are experts in these two areas that can be tapped to explore this more fully.

I would also suggest that using Rosenthal’s An American Sickness as a template for exploring all the waste and profiteering the system would make for good fodder. The cost of inaction continuing to allow this to go on is economically unsustainable.

But as Uwe Reinhardt and Prof. Cheng point out, that while it may not be economically sustainable it is definitely politically sustainable. By that, they mean that the money pouring in to prop up the status quo and to prop up the profiteering makes it politically sustainable.

The next set of costs are the human costs: time, money, illness, suffering, economic suffering, stress. Here are just a few (and each list can be expanded-a lot!):

time spent
- researching health plans
- on the phone with health plans – prior authorization, disputed claims, reviewing explanations of benefits
- trying to get care without insurance
money
- lost wages to pay for employer-based health insurance
- money paid out to get insurance if not offered by the employer
- out-of-pocket expenses for most everything.
- Highly inflated prices due to our “free market” system
illness and suffering
- untreated illness leads to suffering and delay in care and sometimes death.
- Suffering due to financial impairment is a big deal.
- Going to work sick or injured
Economic suffering
- “financial toxicity”
- this obviously gets tied into time and money and illness and suffering
stress
- obviously related to everything above, but should not be discounted.
- There is research into this area, but I am not familiar enough to expound on it.

We will need to do some brainstorming as to the other costs that I am not listing here. I actually think that the idea of doing the live sessions with the public will elicit vast amounts of material to both populate our story inventory for what I have listed above, but will also grow the inventory of costs of inaction.

Burn The Ships.

Example here is Cortes burning his ships so the crew could not go back. It makes going back no longer an option.

Business example is to encourage people to adopt the new software update, notify them of the loss of support for the legacy software. This creates cost to inaction. So you may not be able to burn the ships, but you can at least refuse to subsidize them any longer.

HCR Lessons:

interestingly enough, one could argue that the requirements of the affordable care act mandating that insurance plans cover the required benefits stipulated in the act was a way of burning ships. You can no longer get really bad policies as you once could. As an aside, I’ve heard many complaints about that fact-people wanted to feel like they were covered with those plans because they can afford them. So they felt that taking those plans away was a great loss to them. It would be interesting to have a discussion about this and about how people feel about it now.

Allowing people to buy into Medicare or Medicaid or public option plan would probably fit under easing uncertainty by allowing people to try with the option to go back. However, once there is adequate buy-in to these options, one can certainly burn the ships by ending the tax subsidy for employer-based insurance and allowing those to die away.

Easing Endowment.

“Catalyzing change isn’t just about making people more comfortable with new things; it’s about helping them let go of old ones.”

“…perceived gains and losses are what matter…” This is analogous to Kahneman’s observation that we don’t choose between things, we choose between descriptions of things.

The case study in this chapter is about Brexit. He makes the point that recasting the vote to leave as regaining control or regaining something made the difference. The vote wasn’t to lose something, it was to regain something.

“It’s not a change; it’s a refresh.”

HCR Lessons:

I need to think some more about the perceived gains and losses of transitioning to a universal healthcare system. I actually think this would greatly benefit from some focus group testing on what the perceived gains and losses are by various segments of the public. I have ideas, but they are just my ideas.

The case study about Brexit does conjure up some opportunities. Take back control of your health care? Take back control from corporations? Take back control from the bureaucrats? Take back control from Wall Street? Lots of things that would benefit from some testing. In

Berger, Jonah. The Catalyst: How to Change Anyone’s Mind (p. 83). Simon & Schuster. Kindle Edition.

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 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.

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!)