Reconciling Anat Schenker-Osorio, Mariana Mazzucato, Jonah Berger, Dan Ariely, Anand Giridharadas, and me.

I have been following the work of Anat Schenker-Osorio, hereafter ASO, for quite some time. But lately I’ve become more of a fan. I found an interview with her from “The Zero Hour with RJ Eskow” podcast from about three years ago. It covered a fair amount of territory for a short interview, and I thought it be worth summarizing and commenting on to help with my own clarity of thinking as I try to synthesize lots of cognitive psychology material around persuasion and changing peoples’ minds. So here we go!

First, Anat Shenker-Osorio is the author of the book “Don’t Buy It: The Trouble with Talking Nonsense About the Economy.” She is also a consultant and advisor in the field of communication and strategic communications, and the host of the podcast that was called “Brave New Words,” and is now called “Words to Win By.”

As has been said many times by many people, our choice of words when making our persuasive arguments matters. It matters a lot. She gives the example here of the difference between talking about the price of a prescription drug versus the cost of a prescription drug. She points that cost implies inherent value while price is simply an arbitrary number assigned by typically, someone trying to sell the item. Cost implies an inherent value and perhaps the cost of producing something. (She later mentions talking about insurance corporations rather than insurance companies as another example.)

This argument ties into another discussion I have recently become interested in from Prof. Mariana Mazzucato, who argues that without a clear understanding of value creation, we risk allowing value extraction to masquerade as value creation, leading to a distorted perception of productivity and value in the economy. In other words, in the same pharmacy example, there is value creation, but it lies with the underlying research, typically done in federally funded institutions, and with the actual whitecoat scientists in the pharmaceutical companies. Contrarily, the value extraction in the industry comes from the administrative and executive overload of trying to name prices that are extraordinarily out of step with the actual cost and value of a product.

ASO argues that the “way we describe these policies makes a measurable difference in terms of both who is persuaded to understand and support them, and equally, if not more importantly, how we galvanize are base to repetition so that our version of the story is the one that’s actually able to dominate” in public discourse. If there is one thing the Democrats are bad at, it’s staying on message and repeating the message ad nauseum. We have a lot to learn from our political opponents on this!

She continues that it’s not simply about convincing people that our ideas are better, but it is contending with the cynicism of the public, particularly in healthcare, that change is even possible. She notes that they are also scared to death of getting rid of the devil they know.

She then makes two arguments about this:

Describing policy and making cogent arguments will never overcome the fear of uncertainty.
Arguing for the financial and economic benefits for something that is essentially an argument about our morality as a nation is never going to work.

The uncertainty argument is critically important. Jonah Berger, in The Catalyst, Chapter 4, reviews the literature on loss or risk aversion. People really dislike uncertainty. Uncertainty undermines actively making changes and can halt the decision-making process entirely. “[W]hile uncertainty is great for the status quo, or whatever people were doing before, it’s terrible for changing minds.” “Status quo bias” or favoring something simply because it’s this certain thing that we already know and have is powerful. As Uwe Reinhardt put it long ago, “everybody’s second choice is the status quo!” Therefore, it wins. More here.

The second part of her argument is an echo of a chapter in Dan Ariely’s book, Predictably Irrational. In Chapter 4, “The Cost of Social Norms,” he describes how differently we process decisions based on whether the appeal is to “market norms” or “social norms.” He gives the example of asking a lawyer to do pro bono work for a good cause versus asking a lawyer to do work at discounted rate for good cause. They will nearly always do the former and almost never the latter. Once a rate of exchange is applied to the transaction, it becomes a market transaction and the appeal of doing something as a social good is out the window.

So ASO’s point about not making the typical liberal nitty-gritty detailed policy argument about the market benefits of universal healthcare is spot on. The argument has to turn on social justice and moral norms.

She further emphasizes that point by noting, as would George Lakoff and Drew Westen, that when you make the arguments as financial and economic you activate the parts of the brain, the neurologic pathways that favor conservative arguments of fear of the unknown. And besides, as far as energizing the progressive base, it really isn’t about the economic arguments, even as persuasive as they are, it really is about the moral argument. I know it is for me.

She gives three examples of progressive campaigns that she participated in including the fight for abortion rights in Ireland, the campaign for prime minister in New Zealand, and an anti-racism campaign in Minnesota. She points out that messaging around being against things really doesn’t work well. Progressives need to figure out how to forcefully state what we are in favor of. “Abolish ICE,” for example. It is better as an argument to “create fair immigration process that respects all families.”

One of her central points tying these three campaigns together is the idea of the inevitability of change. Rather than trying to convince people that change was necessary, argue that change is necessary and inevitable. In the abortion example particularly, this was about getting the change over with, because it painted Ireland as backwards and out of step with the modern world. I think the same argument applies directly to America and universal healthcare. We will eventually do this, what are we waiting for? It makes us look bad: selfish, uncaring and backwards. We should lean into that.

Anand Giridharadas in an appearance promoting his new book, The Persuaders, makes a good case for reframing Medicare-For-All as “FreedomCare” in a recent “Off-Line with John Favreau” podcast:

Let’s help people see themselves in Medicare for all. I would call it FreedomCare. I think it’s ridiculous that it’s that it’s called Medicare for all. Why is it named after a government program instead of a widely held American value that would be an example of sticking to the ambitious demand, but saying what are some other ways of talking about it, right?

A language of freedom is a much more resonant language in this country. Healthcare is a human right is something that people – progressives – often say about Medicare for all well that’s actually not a particularly resonant frame in America because it’s not like the people who don’t like universal healthcare also don’t like human rights, right?

What I think universal healthcare would be in truth would be a massive expansion of human freedom in this country. Like I don’t want my boss dictating whether my kid gets care if, heaven forbid, my kid gets cancer. Did you want your boss having that decision over you, right? Yeah, like I don’t want to not pursue my business idea because I have to stick to a stupid job for healthcare.

It’s amazing to me how little progressives speak in this kind of language of personal Liberty around the stuff. That’s the kind of persuasion that I think the characters I’m writing about are interested in.

But let me tell you where she really made me a fan: she wants us to name the villains! This is something I have been pushing in my circles for quite some time, so it is great to hear it validated! She talks about the positive messaging and to say what we are for, but she doesn’t discount the importance of name checking the problem and deliberately naming the villains! She uses the example of the 2009 housing crisis: people didn’t lose their homes, their homes were taken from them by Jamie Dimon and J.P. Morgan Chase and all their collaborators. We have to lose the passive construction of our arguments and assign deliberate causation to the actions of the “malefactors of great wealth.”

There are hundreds of ways that this will work in healthcare. In fact, if you ask Chat GPT who the five highest-paid health ~~plan~~ insurance corporation executives are, it’ll tell you.

1. Bruce Broussard, Humana – $17.3 million

2. Joseph Swedish, Anthem – $13.1 million

3. Stephen Hemsley, UnitedHealth Group – $12.4 million

4. Kenneth Burdick, Cigna – $11.6 million

5. Andrew Slavitt, Optum – $10.8 million

Her final point is based on a quote from Keith Ellison, Atty. Gen. of Minnesota who said, “power knows exactly what it’s doing.” The argument is that speaking truth to power is not enough. The goal is to achieve enough power and force change. FDR allegedly said to a group of activists, “You’ve convinced me. Now go out and make me do it.”

Let’s do that.

Using Catalyst as framework for Moral Healthcare Chapter 1: Reactance

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

The Need for Freedom and Autonomy

Berger, Jonah. The Catalyst: How to Change Anyone’s Mind (p. 20). Simon & Schuster. Kindle Edition.

Example 1: anti-smoking campaign based on telling teenagers not to smoke backfired. Same with the tide pod ad campaign with Grabowski. Simply telling people does not work. They push back-reactance.

What does work is amplifying freedom and autonomy. He uses the example of a nursing home where residents get more choice in their living arrangements and activities.

HCR Lessons:

Telling people that single-payer or some other solution is the correct answer will not work. It creates reactance. For me, I have thought for more than a decade that the solution is to provide people with memorable examples of excellent healthcare in other nations. This is based on the prospect theory ideas of recency and availability. Currently, when people are engaged about universal healthcare, recency and availability leads them to think of long wait times and rationed care. That is no accident. Conservatives have spent years and tons of money making it that way. They have a few choice anecdotes about sad stories of individuals in Canada or the UK and they can trot them out endlessly. They never get old, they reinforce what conservatives have been reinforcing for decades and so positions harden, rather than soften when we present examples of good care and other nations.

We have not done the groundwork to make the excellent care available in other nations recent and available. We need to do a lot of work showing how the choice is not between healthcare in a Soviet Gulag and the current mess we have now, rather it is between the current mess we have now and universal, simple, and affordable healthcare without wait times without the hassles and far cheaper.

We can further expand in this area by making clear that what we want in our freedom and autonomy is not which commercial health insurance plan we get to choose from-the lesser of a 1000 evils-but freedom to choose our doctors and hospitals and be the captain of our healthcare ship.

Prior authorization is freedom denied. High out-of-pocket expenses are freedom denied. Spending countless hours dealing with bills and explanation of benefit forms and appeals and the whole mess is freedom denied. Et cetera, the examples are endless. (BTW, we put together a piece in response to Frank Luntz’ 2009 guide to talking down the ACA, and it is pretty good along these very lines of thought.)

He points out that people are loath to give up agency. They have been told for decades that having employee-based health insurance is somehow agency. I think the experience of most of us with employer-based health insurance is anything but an exercise in autonomy. How many hours have we as individuals and as a society devoted to choosing among multiple health plans from our employer every year? If there were a choice that included near-complete coverage, minimal out-of-pocket expenses, no lifetime limits, unlimited choice of doctors and hospitals and basically what most citizens of developed nations expect as a given, who would not make that choice? Instead, our agency is to choose among the “cream of the crap,” as Paul O’Neill would say.

Reactance and the anti-persuasion radar.

People often take contrary position because they feel like they are being asked to do something. Not even commanded, just asked. People will even resist initiatives that they themselves wanted simply because they become mandatory or imposed in some way. Avoidance is the most common defense mechanism-simply ignoring the message. If they cannot avoid the message, they will cognitively shoot down every component of the message including content and source.

HCR lessons:

This is tough in these highly partisan times. Having content and sources that can at least partly tear down the barriers may end up being key. That is why I think that pairing doctors and nurses to deliver these messages might be key. Doctors are generally trusted, and nurses even more so. And as his corroborating evidence chapter discusses later on, having multiple sources from different areas is more powerful than, say, 5 doctors from PNHP.

Allow for Agency

Important discussion here about getting the perspective of the target audience. He uses the antismoking campaign example and tells how the team asked teenagers for their perspective on the antismoking campaign. They let the teens themselves craft the messages and in this case the messages of tobacco industry manipulation of the public and the political system. “Here is what the industry is doing, they said. You tell us what you want to do about it.”

HCR lessons:

Clearly this can be a powerful tool. We know what the medical industrial complex has been doing for decades. We can craft the messages straight out of Elizabeth Rosenthal’s An American Sickness, chapter by chapter!

I love the example of creating workbooks showing, exactly as Katy Porter did with Revlimid, exactly how pharmaceutical pricing impacts executive pay. (I think it would be also a fun exercise to show how that pricing translates into bonuses for the workers at the company, particularly the scientists who actually do the beneficial work in the industry.)

The other example about the teenagers calling out the magazine executive about not running anti-smoking ads as a public service practically writes itself when translated into healthcare. “Is this about people or about money?”

Berger notes that this campaign worked because it did not tell teenagers to stop smoking, it gave them information from their peers, and they were given agency to make a decision. This encourage them to be active participants rather than passive bystanders, Berger notes.

Creating agency reduces reactance and allows room for action. I can see campaigns pointing out the exorbitant costs of insulin or other medications, the “financial toxicity” of illness, and allowing the public to make up its mind about the acceptability of all this. Of course, there are thousands of other examples that doctors and nurses and health policy experts can give to create ads.

Four key ways to do that are: (1) Provide a menu, (2) ask, don’t tell, (3) highlight a gap, and (4) start with understanding.

Provide a Menu: Let them choose how they get where you are hoping they’ll go.

Provide the trade-offs upfront, as when negotiating salary versus paid time off in Berger’s example. Or, as one selecting off a menu at the restaurant-you are limited to what is on the menu, but there are still many choices. Or offering multiple choices of direction to a client when pitching something. Getting to choose between multiple options reduces reactance.

HCR lessons:

This is why I still I think the single-payer movement is doomed. It presents a single choice as the best choice and only choice.

Ask, Don’t Tell

The example here is a good one about asking students about their expectations of the hours required to prep for a GMAT exam. Basically, this is allowing for an interaction that lets the student figure out, by providing information and feedback, a more realistic study schedule.

This shifts the student from reactance and thinking of all the reasons to disagree or discount the information, the student becomes actively trying to figure out a real answer. Their opinion is valued.

Being able to ask questions increases buy-in. Asking questions that inform their thinking makes them participants in creating the best answer for them.

Berger writes that questions encourage listeners to commit to the conclusion. Asking the question framed around the student’s goals allowed them a path to the solution.

HCR lessons:

I went to the Mob Museum in Las Vegas a couple years ago. One of the things that caught my attention was the Kefauver commission. Sen. Kefauver went around the country holding hearings on organized crime and the effects on the communities he was visiting. This did 2 things. It raised awareness and humanized the crimes. They were no longer ephemeral.

When I was reading the section, I couldn’t help but think how powerful it would be to do sessions around the country with the goal of highlighting the negative effects of the medical industrial complex on ordinary people and then giving them the chance to ask questions of knowledgeable doctors and nurses about potential solutions. For me, this must be people knowledgeable about international healthcare systems. I think the answers are out there and we simply refuse to look for them. Having knowledgeable people be able to answer questions about how we solve X problem and being able to offer a tried-and-true international example would be powerful.

“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.

Highlight a Gap: show the disconnect between what we do or think versus what we might recommend to others.

The important example in this section is about killing off something that is ongoing. He uses the example of a project within a business that is being proposed at the current moment would not be started, but as an existing ongoing project, it is hard to kill it. He attributes this to inertia and somewhere in another chapter he does talk about status quo bias and endowment.

HCR lessons: clearly this should be an important strategy for healthcare reform. I think there are very few people, conservative or liberal, who would create the US healthcare system as it is if they were designing a system from scratch. Some conservatives might argue for at least some of the pro-business, pro-market portions, but very few would argue to keep the system even close to what it is. And pulling confirms this, with a large majority of Americans thinking the system needs to be rebuilt entirely or have major changes. The cost of doing nothing in “blood and treasure” is enourmous.

Start with Understanding.

“Before people change, they have to be willing to listen.”

You cannot start a discussion jumping immediately to the outcome you want and expect people to come along. You must listen to them and understand them first. This requires understanding the other person, gaining insights appreciating their situation. Start by building a bridge.

Tactical empathy allows for not only showing compassion, it also allows one to gain valuable information. Using phrases like you and I, using us and we while working out and working towards solutions is of great value.

It is helpful if by using these techniques the other person feels as if the solution was their idea, or at least partly their idea. (Similar to the GMAT example.)

The other example he gives is not about a hostage situation, but about a suicidal father. The key here is pointing out to him his actions’ effect on his kids. “When people feel understood and cared about, trust develops.”

HCR lessons:

of course, these ideas are powerful in dealing with individuals, but I would circle back around to the Kefauver commission type events. Imagine talking to members of the audience, learning their concerns and developing trust. (As I am brainstorming this, I imagine some truly great ads could come out of the recordings of these sessions!)

Understanding their fears and concerns about transitions to universal healthcare are key. Just like in the Kaiser surveys, when asked about universal healthcare support is two thirds. Add to the question that one would lose one’s employer-based insurance, the support drops in half. This is natural, it is loss aversion. We need to understand the concerns of someone who has employer-based insurance and their fears. We need to allay those fears. We need to understand and offer solutions. In the case of developing a good universal healthcare system, the upsides are protean if you are aware of them. If not, you just think of care delayed and care denied. And, as part of my theme about our vast moral gap on these questions, transitioning to support of universal healthcare means letting other people “get over on you.” (A discussion for another article.)

There’s a Mark Twain quote, “Compassion is such a basic human emotion that it has even been observed among the French!” In spite of the fear of many of having other people get over on them, people are also generally compassionate. Uwe Reinhardt says something along the lines of “Americans are capable of both magnificent generosity and unfathomable cruelty.” The idea of talking about our children and our community’s children and their community’s disabled and poor and so on might be powerful. It would make for some interesting testing, but, it would be consistent with Kalla and Brickman and the deep canvassing techniques covered later in the book.

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

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.

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

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

Using Catalyst as Framework for Moral Healthcare Chapter 4: Uncertainty

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

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

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

Getting People to Unpause

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

Four key ways to reducing uncertainty are to:

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

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

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

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

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

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

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

Taking Advantage of Inertia

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Translation Problem

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

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

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

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

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

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

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

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

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

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

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

Using Catalyst as Framework for Moral Healthcare: Epilogue

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

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

The final summary in the Epilogue:

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

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

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

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

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

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

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

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

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

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

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

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

Cognitive Science & Universal Healthcare

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

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

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