Category: Framing

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 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?

  1. Find the Movable Middle

Example given is about changing minds during election cycle. People are at least somewhat responsive to messaging on issues, like ballot initiatives. On general election candidates? Not so much. Essentially no effect on getting people to change their votes. This dovetails with Ezra Klein’s book, Why Were Polarized. Negative partisanship is powerful and there are very few in that movable middle any longer.

The key here is to find issues on which there are moderates who are persuadable and targeting them specifically with the message-not the broader public. Persuading people that candidate is in the range of rejection on an important issue can move the needle.

Techniques: look-alike targeting, testing and learning to create data, targeting the vulnerable subgroup.

Nice to haves versus need to haves. Things that are imperative versus things that can be put off until later.

HCR lessons: Progressive legislation course requires the election of progressives. But softening the electorate to favorably predisposed him to universal healthcare will require us to move those in the middle to favoring universal healthcare. I think targeting those whom we find in look-alike groups might be fertile ground. Suburban women? Working low income people? Self identified Christians-harkening back to the Book of Matthew and the Sermon on the Mount might be useful strategies. As Berger points out, they will need to be a lot of testing and learning to create the data and then to target the suitable groups.

  • Ask for Less.

As simple as it sounds. Instead of asking people to support say Canadian style single-payer system, ask them if they would support expanding insurance for the unemployed for example. This can then later be parlayed into asking for a bit more and bit more.

HCR lessons: I think this is clearly the way to go. The pushback to a massive change is just to great to ignore. If by some miracle we got a wave election like Johnson got, that would be one thing, but with partisanship as it is, this may never happen again. Given that, we have to scale back our goals and focus on changing people’s minds about lesser advances.

While policy prescriptions as information drops will not change anyone’s mind, changing minds about specific issues that could get significant majority support, like insurance for the unemployed or working poor might.

  • Switch the Field to Find an Unsticking Point.

Deep canvassing example here regarding finding out why people were against Prop 8 in California.

“A single ten-minute “deep canvassing” conversation made voters significantly more accepting. They had more positive feelings toward transgender people and were more supportive of laws protecting them from discrimination. And the effect wasn’t just short-lived. It persisted months after the canvassers had stopped by. It even withstood exposure to attack ads from the opposition.” Deep canvassing also creates “active processing.” This occurs when the person does most of the talking and thus most of the thinking. This encourages people to find a parallel situation from their own experiences to think about.

Finding an area of agreement is called in unsticking point. It takes an abstract debate and make some more concrete discussion about love and diversity in this case. More about what it is like to be left out or judged negatively or be the victim of something or other. The discussion revolves around finding common ground to get around the sticking point. It also involves getting people to tap into their best selves.

HCR lessons: While I think individual deep canvassing can be accomplished by laypeople and may be more impactful if these individuals have truly moving stories, I think in order to move larger groups of people will take doctors and nurses. While I have no doubt one can create empathy in deep canvassing sessions and create active processing, I think at some point this will have to be accomplished on a larger scale.

I am extremely fond of and optimistic about a modern-day Kefauver Commission equivalent. The Kefauver Commission held hearings in 14 cities across the country, and more than 600 witnesses testified. Many of the hearings or broadcast on live TV and provided many with their first glimpse of organized crime in America.

Our “Healthcare in America” Commission could easily list doctors, nurses, pharmacists and other healthcare workers as well as patients victimized by the system. The American healthcare system is capable of miracles but also of base cruelty. The base cruelty is apparent to the victims, largely unknown to the upper-middle-class. Lesser cruelties, the ongoing rationing of prior authorization and high out-of-pocket expenses, on the other hand are quite well-known to the middle class. Highlighting stories of “Financial Toxicity”  and America’s ruthless rationing by income should get some attention.

Further, the spotlight needs to be placed on alternatives. Conservatives love to highlight waiting times in Canada or Britain. We need to highlight the stories of the excellent healthcare in other OECD nations. We have to create recency and availability of the American horror story and also of the possibilities all around us if only were willing to learn.

“It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein.” Teddy Roosevelt.

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

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

Using Catalyst as Framework for Moral Healthcare Chapter 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:

  1. 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.

  1. 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.
  2. When?
    1. Sometimes, all at once like in an intervention.
    1. Closely spacing asks or invitations is more impactful.
  3. 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.”

Cognitive Science & Universal Healthcare

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

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

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

Why are conservative attacks on universal healthcare always so lame?

An Astoundingly Tone-Deaf Piece by Sally Pipes in Forbes Magazine.

“The pandemic has revealed the rotten core of single-payer.”

The Agnew Clinic, Thomas Eakins

I can scarcely fathom a more obtuse sentence. Here we are, in America, currently competing to be a shit-hole nation, and Ms. Pipes is so clueless that she thinks the pandemic has exposed other nations’ healthcare problems. Wow. Just wow.

Data from the Kaiser Family Foundation showed the uninsured rate in America, thanks to the Affordable Care Act, had declined from around 17% to about 10%. So, as of 2018, about 27.9 million people in the US were uninsured. (For those of you who have not had the misfortune of reading Ms. Pipes work, these 27. 9 million people can’t even qualify for the horrific queues Ms. Pipes laments about.) Since the pandemic, these numbers have skyrocketed, as Mr. Trump might say. With the massive waves of unemployment due to the pandemic, Families USA estimated more than 5 million laid-off workers joined the ranks of the uninsured. They, too are not even eligible to get in the queues for care that Ms. Pipes laments.

Ms. Pipes points to the sad case of a man who died from kidney failure due to delayed elective surgeries in Canada. Sad, of course, but Ms. Pipes is no doubt aware of the saying attributed to Stalin, “A single death is a tragedy; a million deaths is a statistic” While Ms. Pipes is lamenting the Canadian system for this tragedy, the US healthcare system is guilty of the statistical heap of deaths due to kidney failure in the US. According to the CDC via the National Kidney Foundation:

Early referral to nephrology is associated with improved CKD outcomes, however Black or African American patients are more likely to have delayed referral or no nephrology referral at all. Communities of color are also overrepresented among patients with end-stage kidney disease. For every three non-Hispanics who develop kidney failure, four Hispanics develop kidney failure. Black or African Americans are three times more likely to suffer from kidney failure than Whites.

Pipes notes that three dozen people have died in Ontario due to cancelled heart surgeries. I hate to make light of this, because, you know, most Canadians care about each other and this bothers them. But in America, this is chump change, in terms of the cost in human lives. Again, More than 30 million Americans can’t even get into the queue for the cancelled heart surgeries. As Ms. Pipes probably knows, showing up in the Emergency Department actually having a heart attack does not turn out as well as having a primary care doctor you can afford to see and maybe try to avoid the heart attack in the first place. According to the American Heart Association (references omitted),

Americans with CVD risk factors who are underinsured or do not have access health insurance, have higher mortality rates and poorer blood pressure control than their adequately insured counterparts. Uninsured stroke patients also suffer from greater neurological impairments, longer hospital stays, and higher risk of death than similar patients with adequate coverage. Not having coverage or having inadequate coverage also impacts patients’ financial stability. More than 60% of all bankruptcies in 2007 were a result of illness and medical bills – more than a quarter of these bankruptcies were the result of CVD. Nearly 80% of those who filed for medical bankruptcy were insured. Additionally, uninsured and underinsured patients are more likely to report access issues related to cost, including not filling a prescription, forgoing needed specialist care, or even not seeking medical care during an acute heart attack. Delaying care can have huge negative consequences for both patients and for the healthcare system. To that extent, it is clear that not having access to quality, comprehensive health coverage and care is bad for patients.

Her next example is a woman from Nova Scotia who had to resort to a GoFundMe campaign to pay expenses for lung transplant surgery! Can you imagine? Oh, wait, about half of all money raised on GoFundMe is for medical expenses. The Guardian recently reported that “25% of Americans say they or a family member have delayed medical treatment for a serious illness due to the costs of care, and an additional 8% report delaying medical treatment for less serious illnesses.” BTW, the Guardian sites an anecdote about a woman who called in sick due to pneumonia and lost her job and her health insurance for exceeding her employer’s attendance requirements by one day.

And speaking of financial hardship, or the “financial toxicity” of disease, researchers reported in 2018, pre-pandemic, that, for Americans newly diagnosed with cancer between 2000-2012, at just year two, 42.4% had depleted their entire life’s assets, with average losses of $92,098. Only 7.9% of these were uninsured.

The overarching theme of this piece is that somehow citizens with universal and affordable access to care are paying a steeper price than those of us with an unreliable and expensive healthcare infrastructure. She gives examples of people with access to universal, affordable healthcare are now caught in a backlog due to the pandemic. That is awful. But, the idea that America is somehow immune to the disruptions necessitated by COVID-19 is so ludicrous that I don’t think it needs dignified with a reference. If the planet you are living on has not allowed in enough oxygen to allow you to not see what utter nonsense this is, then you stopped reading this a long time ago!

This wouldn’t be a Sally Pipes piece without a partisan attack, and she does not disappoint, attacking Joe Biden and Democrats for working towards universal healthcare. She closes with this precious line, “The pandemic has revealed the rotten core of single-payer.” I have been saying for some time now that avarice and amorality are the rotten core of American Healthcare, and the pandemic has, as possibly it’s only upside, exposed the truism that American healthcare is a mess.

Cognitive Science Lessons.

People like Ms. Pipes have spent decades making sure that stories like the ones she has in her articles are pushed front and center in people minds. It is very effective in insuring predisposition to opposing healthcare reform for the following reasons:

  1. Recency Effect and Availability Bias. Placing narratives, especially emotionally charged ones, as Pipes’ does expertly, is a powerful tool. It activates our mind in several ways. Because we hear stories like these repeated by conservatives over and over again (mostly the same set of stories), they are both recent  and available,  and thus come to mind when we are asked to think about universal healthcare. When there is a discussion of the topic, these types of anecdotes come to mind and reinforce opposition, if that is our predisposition, to change. The obvious counter to this is to make the “American Horror Stories” that physicians, nurses and really anyone who has had an interaction with the healthcare system, know so well, and tell those thousands and millions of stories! Even for someone who has run the gauntlet and gotten the crowning jewels of medicine, like a transplant or interventional procedures or survived sepsis in the ICU, it is rare to not have numerous tales of the hassles of prior authorization and “explanation of benefits” forms and bills and checks and everything that makes the business of medicine such a horror show.
  2. Loss or Risk or Dread Aversion. Knowing or hearing stories of dreadful outcomes creates powerful aversion in us. If we hear stories of people not receiving care and dying, that arouses significant emotions and colors our assessment of a problem. Thus, when stories are recent, available to our minds readily and scary, they are impactful. And as with the former effects, those who know the benefits of universal healthcare that we see around the world, and the horror show we see here in America, this should be our wheelhouse. We have the stories of the heartlessness and cruel rationing of care in front of us every day. We need to collect them and use them. Recency, availability and dread aversion need to become the friends of advocates for universal healthcare.
  3. I was going to add a third point here about the pro-business, pro-corporate brainwashing that has occurred in the US over the past half century or so, but rather, I’ll just ask you to read Anand Giridharadas’ Winners Take All,  or at least get a taste of it here in this Guardian review. And for those who think private corporations always handle things better than government or other public agencies, I’ll just ask you to recall the last time you called your a) cable company b) health insurance company or c) well, almost any large corporation.

Winning over the disaffected to Universal Healthcare #UHC

Someone who clearly knows how I think sent me this article – The Facts Just Aren’t Getting Through today from The Atlantic. Thanks to Anne Applebaum for some great ideas!

If you read it through my eyes, always looking for ways to convert others to the Universal Healthcare (#UHC) Team, several things stand out:

  • The Republican Voters against Trump ads use members of their own tribe to express disillusion.
    • There are many disillusioned members of the Medical Industrial Complex.
    • We need to start identifying them in preparation for a UHC campaign using their insights.
    • Like Wendell Potter, they can provide perspective for the currently trapped.
  • There is value in helping the disaffected realize that they can find community among others who believe like them, even as they separate from another ideological community.
    • “You won’t be left alone!”
    • There are many others like you disillusioned and angry at a system that mistreats so many of our fellow citizens.
    • Leaving a community that believes that the suffering and dying of our disadvantaged is just part of the “American Way,” should be easy. They just need a new community. Us.
  • Humor melts fear.
    • Having been an intensivist most of my career and then a hospice doc, I can tell you that medical humor can be very dark.
    • We in the medical community might need some guidance in channeling our humor in a more gentle way…

Stunning Healthcare Overture from Bipartisan Group of US Senators – 2007

Healthcare Legislation in This Congress? – Michael Barone (usnews.com)

I followed Ezra Klein’s link to this letter from 10 Senators, 5 Republicans and 5 Democrats, written just two years before President Obama took office! Read it, as it is stunning how far the Republican Choo Choo has gone around the bend.  [Courtesy USNews.com and Michael Barone.]

Now Wyden and nine other senators, five Democrats and five Republicans, have sent the following letter to Bush. Very interesting.

In addition to Wyden, the letter was signed by Republicans Jim DeMint of South Carolina, Robert Bennett of Utah, Trent Lott of Mississippi, Mike Crapo of Idaho, and John Thune of South Dakota, and Democrats Kent Conrad of North Dakota, Ken Salazar of Colorado, Maria Cantwell of Washington, and Herb Kohl of Wisconsin.

The text of the letter follows:

February 13, 2007

The Honorable George W. Bush
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mr. President:

As U.S. Senators of both political parties we would like to work with you and your Administration to fix the American health care system.
Each of us believes our current health system needs to be fixed now. Further delay is unacceptable as costs continue to skyrocket, our population ages, and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for “free.”
We would like to work with you and your Administration to pass legislation in this Congress that would:
1)Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage.
2)Modernize Federal tax rules for health coverage. Democratic and Republican economists have convinced us that the current rules disproportionately favor the most affluent, while promoting inefficiency.
3)Create more opportunities and incentives for states to design health solutions for their citizens. Many state officials are working in their state legislatures to develop fresh, creative strategies for improving health care, and we believe any legislation passed in this Congress should not stymie that innovation.
4)Take steps to create a culture of wellness through prevention strategies, rather than perpetuating our current emphasis on sick care. For example, Medicare Part A pays thousands of dollars in hospital expenses, while Medicare Part B provides no incentives for seniors to reduce blood pressure or cholesterol. Employers, families, and all our constituents want emphasis on prevention and wellness.
5)Encourage more cost-effective chronic and compassionate end-of-life care. Studies show that an increase in health care spending does not always mean an increase in quality of outcomes. All Americans should be empowered to make decisions about their end of life care, not be forced into hospice care without other options. We hope to work with you on policies that address these issues.
6)Improve access to information on price and quality of health services. Today, consumers have better accessto information about the price and quality of washing machines than on the price and quality of health services.
We disagree with those who say the Senate is too divided and too polarized to pass comprehensive health care legislation. We disagree with those who believe that this issue should not come up until after the next presidential election. We disagree with those who want to wait when the American people are saying, loud and clear, “We want to fix health care now.”
We look forward to working with you in a bipartisan manner in the days ahead.

Skyrocketing costs! Competetive disadvantage! Universal access to health care! Class warfare! Inefficient US health care! Wellness! Prevention! Cost effectiveness! Compassionate end of life care! Expanding palliative care services! Health care in the US is broken!

Who knew Jim DeMint was a socialist before he was a Tea-Partier?

George Lakoff: The Wisconsin Blues

George Lakoff: The Wisconsin Blues

Scott Walker was just carrying out general conservative moral policies, taking the next step along a well-worn path.
What progressives need to do is clear. To people who have mixed values — partly progressive, partly conservative — talk progressive values in progressive language, thus strengthening progressive moral views in their brains. Never move to the right thinking you’ll get more cooperation that way.
Start telling deep truths out loud all day every day: Democracy is about citizens caring about each other. The Public is necessary for The Private. Pensions are delayed earnings for work already done; eliminating them is theft. Unions protect workers from corporate exploitation — low salaries, no job security, managerial threats, and inhumane working conditions. Public schools are essential to opportunity, and not just financially: they provide the opportunity to make the most of students’ skills and interests. They are also essential to democracy, since democracy requires an educated citizenry at large, as well as trained professionals in every community. Without education of the public, there can be no freedom.
At issue is the future of progressive morality, democracy, freedom, and every aspect of the Public — and hence the viability of private life and private enterprise in America on a mass scale. The conservative goal is to impose rule by conservative morality on the entire country, and beyond. Eliminating unions and public education are just steps along the way. Only progressive moral force can stop them.
The Little Blue Book is a guide to how to express your moral views and how to reveal hidden truths that undermine conservative claims. And it explains why this has to be done constantly, not just during election campaigns. It is the cumulative effect that matters, as conservatives well know.