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.

Even Critics of Safety Net Increasingly Depend on It – NYTimes.com

It speaks for itself…

LINDSTROM, Minn. — Ki Gulbranson owns a logo apparel shop, deals in jewelry on the side and referees youth soccer games. He makes about $39,000 a year and wants you to know that he does not need any help from the federal government.

He says that too many Americans lean on taxpayers rather than living within their means. He supports politicians who promise to cut government spending. In 2010, he printed T-shirts for the Tea Party campaign of a neighbor, Chip Cravaack, who ousted this region’s long-serving Democratic congressman.

Yet this year, as in each of the past three years, Mr. Gulbranson, 57, is counting on a payment of several thousand dollars from the federal government, a subsidy for working families called the earned-income tax credit. He has signed up his three school-age children to eat free breakfast and lunch at federal expense. And Medicare paid for his mother, 88, to have hip surgery twice.

Even Critics of Safety Net Increasingly Depend on It – NYTimes.com

Public in Deep South supports expanding Medicaid, poll finds, but lawmakers don’t – KansasCity.com

WASHINGTON — Even though governors and lawmakers in five Deep South states oppose a plan to cover more people through Medicaid under the health care overhaul, 62 percent of the people in Alabama, Georgia, Louisiana, Mississippi and South Carolina support expanding the program, according to a new poll.
The level of support for expanding Medicaid – the state and federal health insurance program for the poor and disabled – ranged from a low of 59 percent in Mississippi to a high of 65 percent in South Carolina, according to the poll by the Joint Center for Political and Economic Studies, a leading research and public policy think tank that focuses on African-Americans and other people of color.
Brian Smedley, director of the center’s health policy institute, said the findings show that lawmakers who are blocking Medicaid expansion in the five states are “out of step with their constituents.”

Public in Deep South supports expanding Medicaid, poll finds, but lawmakers don’t – KansasCity.com

Altmire on Public Option

This is from Firedoglake

List of Blue Dogs who have expressed support for a public option (with Nate Silver’s estimate of district support/opposition in parenthesis):

1. Jason Altmire: (35-53)

Signed HCAN principles

July 17: Voted ‘no’ as a member of the Health & Labor Committee against 3200 because of wealth surtax.

September 11: ‘I – I’m speaking for myself, I think that the public option may, if it’s done correctly may be a part of the package and could play a role. As Congresswoman Woolsey described, it would have to airtight, completely self-sustaining, not funded through taxpayer subsidies, and have to meet all the same insurance regulations. So, I don’t think that is the sticking point for the Blue Dogs and the moderate members. I think what we are most concerned about is we have to do this in a fiscally responsible way.’

September 22: ‘Altmire’s chief complaint about his own chamber’s bill was the inclusion of a surtax on the wealthy. But he said he didn’t expect that provision to make it through, and he signaled that excluding it would allow him to vote for the final bill.’

It looks like we in Western PA have some work to do in getting Altmire’s district turned around. Those are abysmal numbers of support for the Public Option.

Sounds like a job for Doctors for America.

If you would like a doctor to come speak in Mr. Altmire’s district, please let me know and I will do it or find someone who will!

HEALTH REFORM: Poll Shows Hopes, Not Just Fears for Reform | New America Blogs

HEALTH REFORM: Poll Shows Hopes, Not Just Fears for Reform New America Blogs:

The poll doesn’t indicate that Americans would prefer not to have health reform. In fact, the data shows just the opposite. When asked what they though would happen if ‘the government did NOT create a system of providing health care for all Americans,’ a solid majority of people were ‘very’ or ‘somewhat’ concerned that the number of uninsured people in the U.S. would keep increasing, that they themselves might be uninsured at some point and that the cost of their own health care would go up.

To us, the poll doesn’t indicate support is falling apart for health reform — it does mean that uncertainty is on the rise. This is understandable, as a lot of details are still being hashed out and even members of Congress have difficulty quickly grasping all the complexities of the policy options being discussed right now. That’s why it will be important for advocates of reform, including the President, to explain it clearly (and repeatedly) in the coming weeks. Shift the focus from the scary unknown to the known — that the current system is broken, and it’s time to fix it. Because there’s a lot in it for all of us.

In Poll, Wide Support for Government-Run Health – NYTimes.com

In Poll, Wide Support for Government-Run Health – NYTimes.com:

“Across a number of questions, the poll detected substantial support for a greater government role in health care, a position generally identified with the Democratic Party. When asked which party was more likely to improve health care, only 18 percent of respondents said the Republicans, compared with 57 percent who picked the Democrats. Even one of four Republicans said the Democrats would do better.”

Complete Polling Results here.

Check this out: a total of 85% said health care needed either completely rebuilt or fundamental change. And 86% think health care costs are a very or somewhat serious economic issue.

OTOH, 77% are generally satisfied with the health care they personally receive, but 94% recognize that people not having insurance is a very or somewhat serious problem. there is hope!

Data Note: Footing the Bill – Kaiser Family Foundation

Data Note: Footing the Bill – Kaiser Family Foundation:

“This brief data note looks at the raft of polls recently released on the public’s willingness to pay for an expansion of coverage to their fellow citizens. It compares and contrasts findings on Americans’ general inclinations on the topic, and also revisits recent findings on specific revenue raising proposals.”

The file is here: Data Note (.pdf)

Kaiser does all of us a great service by doing the hard work of keeping track of and advancing our knowledgebase on health care, so my comments don’t reflect on them, but…

Thanks for putting together the Data Note on polling.

I find it tremendously frustrating that the questions are asked by organizations in the manner that they are.

The question should never be “would you support raising taxes to cover the uninsured,” the question should be, “”if your wages increased to reflect your employer no longer paying for your health insurance, would you be willing to pay more taxes to cover the uninsured” or, to those without insurance or buying their own, “if you could be covered by a national health insurance plan, would you be willing to pay higher taxes,” or questions like that.

I note in your last section, you point to people believing that this could be done without spending any extra money. This is true, if we adopted a German style Social Health Insurance model or French style single payer model. So, these people are not being foolish, they perhaps just see the tremendous amount of waste in the system and know that if we did things efficiently we would not have to pay more (and I would add, we wouldn’t have to pay more after we got through the transition period that would be required).

So I would like to see some organizations asking questions premised on wholesale reform – transformation to a German or French model – rather than continuing to be asked questions premised on rearranging deck chairs on the Titanic.

“If, rather than minor health care reform, the US adopted a system like Germany’s or Frances, with high quality health care for all, no waiting times, and no danger of losing insurance or going bankrupt due to health care costs, would you be willing to pay higher taxes?”

Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

The hearing ranged broadly over the possibilities for reform, but what clearly resonated for McArthur was something Baucus’ chief of staff, Jon Selib, said a couple of times.

Discussing why a single-payer system of health insurance wasn’t viable, Selib made reference to the more than 150 million Americans who are covered by some sort of employer-provided health care.

“A lot of people like that,” Selib said.

When the time came for questions, McArthur stood up and asked a simple question. Looking across a standing-room-only crowd of about 275, he asked how many were happy with their employer-based health insurance.Less than 10 people raised their hands.

“The number is bogus,” McArthur said. “It’s not working for 95 percent of us.” McArthur drew resounding applause.

In fact, any mention of single-payer health care insurance brought raucous cheers and clapping.

Any other solution to health care reform – including Baucus’ “balanced” plan that would create a mix of public and private plans – was received more coolly.

Tuesday’s session was one of a handful of events Baucus is sponsoring around the state this week. He chairs the Senate’s powerful Finance Committee, and is the point man on health care reform.

He did not attend Tuesday’s meeting, but Selib did, and he heard what the senator himself has heard since he announced that single-payer wasn’t really on the table.

As Selib worked to massage that point, one man barked out, “Oh bull—-.”

Tom Roberts, president of the Western Montana Clinic and moderator at the session, asked the crowd to be civil, but the man had made his point.