Moral Arguments

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.

How Equal Do We Want To Be – in Healthcare?

Along my journey in Cognitive Science I came to discover Dan Ariely, and then came across a TED talk he gave called How Equal Do We Want To Be? He explores economic inequality and what we think we know about economic inequality, the reality of income inequality and finally what we would like income inequality to be. I think there are important correlations to how equal do we want to be in healthcare, and brought this here for discussion.

You can easily skip my summary of his talk and just go over and watch it, but I also wanted to capture some of the graphics, as I think with just a little imagination, they can be transformed into important questions about our healthcare system!

So, from the top! What we think is that the top 20% have 58.5% of the wealth and the bottom 40% have about 10% of the wealth.

In reality, the top 20% have 85% of the wealth the next 20% have 11% in the bottom 60% share the last 5%. He calls this difference between what we think and reality the Knowledge Gap.

Along those lines, he asks what we think the pay ratio of CEOs is to that of unskilled workers. He shows this graph showing what people think it is (Estimated), when it actually is (Actual), and our ideal notion.

Not so bad, right? Oops, he didn’t adjust the scale. Here’s the reality.

We are in Alice in Wonderland territory now. But if you are in the CEO or top 20%, it’s a very happy Wonderland, indeed!

During the talk, Ariely references John Rawls and his theory of distributive justice. He asked whether, if we could design our system, would we choose what we have? So he asks, “How should the wealth be distributed?”

Quite a different picture! The fairness is striking! Sure, those at the top do better, but those at the bottom should not be destitute, either. He calls this difference between what we think we have and what we want the Desirability Gap.

His last step is to ask us not only what do we think we know and what do we want, but what are we going to do about it? This is the Action Gap. There is much activity in the action gap of late. (Well, maybe Bernie Sanders not just lately.) But the recognition of massive wealth inequality finally seems to be making it into mainstream debates on policy in America for the first time in decades.

I will leave that larger societal question to others. My lane is the healthcare line, particularly the fairness of healthcare lane, or the social justice Lane. Ariely notes that he has done research about other areas of inequality including health, availability of prescription medications, life expectancy, infant mortality, and education. He notes that we are even more averse to inequality in these areas than we are regarding wealth. We are even especially averse to inequality when the individuals have less agency, like children. (I would be interested in extending my research to see if it also applies to people born into all lower social economic statuses.)

I do not know if there is research on what Americans think about the injustices or performance of the US healthcare system. I do know that most Americans know that we are not the best and no favor major changes or complete overhaul of the system. And of course, we do know many of the realities. We know we spend far more than any other nation and do not cover everyone. We know we have very high out-of-pocket costs. We know we have relatively low life expectancy and high infant mortality. We know our citizens are less likely to survive serious illnesses. We know that we have less physicians and our people see our physicians less frequently than other nations.

At a baseline, we do not even know what The US Healthcare Knowledge Gap is. We do not know what the public does not know. That makes it hard to get to the Desirability Gap, let alone the Action Gap.

Can we get by without knowing what the Healthcare Knowledge Gap is? Maybe. But it will be nearly impossible to move forward without knowing the Desirability Gap.

This will take some serious work. Not only do we need to do the work to educate people on the reality of American healthcare, we then have to do research to find out what we,or at least what most of us, want to do. After decades of watching progressives telling people that what they should want is single-payer, I know that telling people what they want is not the answer. We need to do some work and we need to have some conversations and we need to come up with solutions.

What Are Physicians Willing To Give Up To Achieve Universal Healthcare?

One of the things that has troubled me for more than a decade is the way the medical profession declares that we favor an equitable distribution of healthcare resources and yet do little or nothing about it. In 2002, the Physician Charter on Medical Professionalism in The New Millennium was published. I will not bore you with the details here, but 2 provisions are important. Commitment to improving access to care and commitment to adjust distribution of finite resources are clearly stated. Physicians are exhorted to “individually and collectively strive to reduce barriers to equitable healthcare” and to be public advocates “without concern for the self-interest of the physician or the profession.”

This charter was signed by essentially every medical society and specialty organization that you can think of. From the American Medical Association to the American Academy of Orthopaedic Surgeons and the American College of Radiology and on and on. And yet, apart from lip service supporting improved access to health care, we have seen essentially no action. (I will be happy to entertain examples of such action in the comment section.)

We have theoretically signed on to the principles of universal healthcare and yet we have also been adamant in opposing and successful in preventing universal healthcare adoption. As a physician, I can find many malefactors for the lack of progression to universal healthcare in America. I don’t need to name them. You know who they are. And they will fight change with a white-hot intensity. As physicians, we can, and do, say “Why should we offer up anything when nobody else is willing to?” Maybe that is fair, but then why have the Charter? Why sign on to the Charter?

I can come up with many reasons why the medical profession has failed America in this area, but I have concluded that most important is that if we are forced to have a real conversation about universal healthcare, we will be asked to give something up and we are not prepared to do that. But until the medical profession steps up, is there really any hope?

The transition to universal healthcare will involve some pain to all of us in the healthcare industry. (Well, most of us anyway. I expect nurses, respiratory therapists, and many other categories of healthcare workers to deservedly make out a bit better, at least!) The question will be about how the pain will be divided. This terrifies physicians. It especially terrifies the highest-paid physicians. It also causes angst among the lowest paid physicians and medical students. Uncertainty is deadly to health care reform.

Consequently, I have been trying to figure out a way to have a conversation about this that makes sense and is fair to everybody. As an aside, I have been telling my generational colleagues, this is not about us. If we made sweeping changes legislatively tomorrow, most of us would be retired or at least close enough to it for any significant economic damage to happen to us.

While on my journey in cognitive science, I came across the philosophy of John Rawls. Rawls was famous for his Theory of Justice, published in 1971. At its heart is this: “A just society is a society that if you knew everything about it, you’d be willing to enter it in a random place.” Rawls proposes the thought experiment in which we place ourselves behind a Veil of Ignorance, not knowing our position in society, and then construct the society.

Rawls was one of the most influential philosophers of the 20^th century and it is horribly reductionist of me to sum his work up in a few sentences, but for our purposes this will suffice. Imagine creating a physician reimbursement system and medical school tuition scheme not knowing whether you will be entering it as a radiologist, pediatrician, hospital or health plan administrator, orthopedic surgeon, or a medical student. You do not know if you will be entering at the beginning of your career or at the end of your career. How would you design the system? How much would medical school tuition be? At Georgetown? At Wright State? How much would a neurosurgeon make? How much would a psychiatrist make? What would be just? What would be fair?

I propose Rawls’ construct is a strong starting point. I can fairly confidently predict that many, if not most physicians will reject out of hand even contemplating this idea. Fear and uncertainty are potent emotions against change, or even contemplating change. But I think we can find a core of willing participants, and we can make an amazing experiment happen. We can bring these people together and have this conversation. Even if the result is just a conversation, it is a beginning. It is the beginning of a discussion of what we as physicians expect from our profession and what we expect from ourselves as professionals. Are we to “individually and collectively strive to reduce barriers to equitable healthcare” and to be public advocates “without concern for the self-interest of the physician or the profession?” Or are we to just continue to pay lip service to these ideals?

This discussion dovetails with a TED talk by Dan Ariely called How Equal Do We Want To Be? You’d be surprised. He explores economic inequality and what we think we know about economic inequality, the reality of income inequality and finally what we would ideally like income inequality to be. Please follow the link to the next portion of this writing…

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.

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

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

– Uwe Reinhardt

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Priced Out

The Economic and Ethical Costs of American Health Care

by Uwe E. Reinhardt

Epilogue by Tsung-Mei Cheng

Forewords by Paul Krugman & Sen. William H. Frist

Reviewed by Christopher M. Hughes, MD

If you are a novice to the subject of health care policy, the first few chapters of Priced Out will leave you dumbfounded at the absolute mess we have made of healthcare in the United States. Professor Reinhardt calls it a “wonderland,” and not in the pleasant sense. The wonderland is the morass of payment schemes that allow a multitude of administrators (insurers, pharmacy benefits managers, etc.) to skim just a few cents off each health care dollar spent before the remainder makes its way to those actually providing services to patients. Example after example highlight the mess we have created at the altar of “the market” or “competition” or the illusion of “choice.”

If you are in the morass, as a physician or nurse or student of health policy, you will sigh in recognition of the things you may have already known, but you will see more clearly with Prof. Reinhardt’s great ability to make the complex comprehensible. For example, the highly “popular” Health Savings Accounts, are known to be a sop to high income households, especially healthy households, but Uwe points out that they have also sprouted a cottage industry of administering these accounts, taking just a little “haircut,” as he likes to say, of the billions of dollars that flow through their accounts each year.

For me, as someone in the morass as a physician, a physician currently working in the health insurance industry and someone who teaches health policy, I was aware of most of the accretions and detritus that make our health delivery system a mess, but Uwe always manages to add this kind of level of detail to, well, just infuriate me! Other examples are the “categories” of human beings we have in the US, from the poor to the near poor to the wealthy, to those covered by Medicare or Medicaid or both or neither or those covered by employer-based insurance to those in the Affordable Care Act Marketplace – or not. He jokes that in most nations, there is only one category of human beings. We have made micro-categories a high art.

Chapters on the outrageously complex mechanisms we use to price services and how we pay the bills are head slapping. Even as one in the middle of the morass, I am still shocked to see the insane specifics of how we have passively allowed this all to go on under the banner of “competition” and “market freedom” and other euphemisms for greed. Convoluted methodologies to “control costs” by external administrative mechanisms rather than evidence-based practice infuriate physicians and have spawned the multitude of staff in doctor’s offices and hospitals to obtain “prior authorization” to prescribe medications or perform surgeries or even to determine if one is sick enough to be in the hospital.

The second half of the book focusses on the social ethic of our health care system. Uwe states it plainly: “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in healthcare?”

This is clearly more troubling to Uwe than the economics or health care and how deranged our system has become. After the failure of the Clinton Health Plan in the 90’s, he wrote a powerful article in the Journal of the American Medical Association (JAMA) called, Wanted: A Clearly Articulated Social Ethic for American Health Care. In it, he asked the precursor to the above question: “should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?” He was clearly stung by the idea that his adopted countrymen rejected this solidarity, in contrast to every other nation’s resounding “yes” to the question.

He explains that our tendency in American political life is to pretend that our disagreements on health care are due to the details and howto get to universal health care. So rather than have the broader ethical discourse that could answer the two extremely important questions he has posed, we camouflage and misdirect and devolve our discussions to the best way to bring market forces to bear or how to properly fund Medicaid in the states. We never answer the basic question of whether we should strive for universal healthcare.

He has said elsewhere, “A common incantation during debates on health reform, for example, is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”

He spends a significant section of the book exploring his framing for this fundamental disagreement among conservatives and liberal. But he does not have an answer for us on how to get where he clearly wants us to go – as explicitly stated by his widow, TM Cheng in her epilogue – “he passionately believed in universal healthcare.”

In an exchange I had with him a few years ago, he wrote, “the problem in America is that the elite does not share a consensus on what the social ethic governing American health care should be. I am not sure it ever will reach such a consensus.”

In the epilogue by Dr. Cheng, she documents his hopes and thoughts and, surprising to me, his optimism in America. We would hobble along, he thought, and continue to figure things out as we went, and perhaps technology can improve our lot.

The book left me less optimistic about our chances to reach consensus, but more committed to trying to make it so. Profs. Reinhardt and Cheng spent decades trying to advance American healthcare and continually try to engage on the ultimate questions of our social ethic, paraphrased by Michael Moore in Sicko as, “Are we about me, or we?”

The glimmer of hope I still have rests on two foundations. Uwe’s clear-eyed articulation of the questions we have before us and their obvious answers and my faith in the doctors and nurses who provide healthcare in the trenches, as we like to say, and who have long ago had enough.

In 2002, “Medical Professionalism in the New Millennium: A Physician Charter,” was published as a Project of the ABIM Foundation, the ACP–ASIM Foundation, and the European Federation of Internal Medicine. In the Charter are calls around the Principle of social justice, Commitment to improving access to care, and Commitment to a just distribution of finite resources. It specifically charged the medical profession to “promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

The Charter argues that “Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.”

This Charter has been endorsed by virtually every group within organized medicine, from the American Medical Association to the American Board of Radiology to the American Nurses Association. While it is not explicitly a call for universal healthcare in America, it is hard to view the principles and not see this as the logical conclusion. And in fact, at the time of its publication, there were quite a few dissenting commentators who saw it as just that, and so rejected it.

I am taking Prof. Reinhardt’s last book as the plainspoken economic and practical case to shake ourselves free from this embarrassment of a “system” we have watched become a more hideous monster than we ever contemplated. I am also taking it as the simple moral argument for whywe need to change. We must stop allowing ourselves to be pulled into discussions about what flavor of health care reform we like best, and have that knock-down, drag-out fight about who we are as a nation. Are we the nation that cheers when one of us gets struck by a car and is left to die because they chose to forego health insurance? Or are we the nation that sees ourselves in the suffering of others and wants to help?