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.

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Notes and thoughts: Thinking fast and slow about universal healthcare.

Thinking fast and slow about universal healthcare.

I have been thinking about healthcare reform in general and universal healthcare in particular, for decades now. I am well aware of the admonition of Uwe Reinhardt that, in healthcare reform, everybody’s 2^nd choice is the status quo, and thus reform is hard-fought. But, because of an excellent book by Michael Lewis, The Undoing Project, about the world changing work of Daniel Kahneman and Amos Tversky, and Daniel Kahneman’s own book, Thinking Fast and Slow, I have been able see more clearly why healthcare reform is so damned difficult.

The major concepts explored in Tversky and Kahneman’s seminal work on Prospect Theory and in Kahneman’s book explain the failure of healthcare reform in America better than nearly anything I have explored before. The only caveat I will add to this is that as the late Uwe Reinhardt pointed out, Americans have also steadfastly refused to have the moral argument about whether or not we should even strive for universal healthcare, let alone how we should get there! “A common incantation during debates on health reform… is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”

Thinking is divided into fast and slow subsets. System 1 thinking is fast and intuitive. It is also confident. Overly confident, according to Kahneman. System 2 thinking is slow and deliberate. It is more difficult, it takes more time, it is less confident.

System 1 thinking leads many to believe that any changes to the US healthcare system that would make it more like any other nations healthcare systems would be bad. This thinking occurs with minimal or no actual reference data, other than what it picks up from its favorite news sources. If the person has seen a story or two about waiting times in Canada, or a patient not getting timely care in the UK, system 1 confidently trashes any talk of change. The medical analogy, as taught to me during my medical school days is, “One half-assed observation by me is equivalent to 3 randomized controlled trials.”

Kahneman uses the following example: a bat and ball together cost $1.10.

The bat costs a dollar more than the ball.

How much does the ball cost?

People intuit what is an incorrect answer, 10 cents, and confidently do so, because they did not check. The answer is easy, but System 1 intuition confidently plows ahead with the incorrect answer.

Politicians, pharmaceutical and health insurance industries as well as the many support industries around them, promote this thinking, in a constant multimedia barrage, reinforcing false intuitions.

System 2 thinking is less confident and more deliberative. It takes longer. It requires more effort. It requires a commitment. Thus, it too often takes a backseat to our intuitive thinking.

All of our thinking is subject to the other forces outlined in prospect theory, namely, reference points, loss aversion, framing, availability, and the sunk cost fallacy.

In classical economic Utility Theory, the dollar is a dollar. $5 million should make us happy. But if I start with $1 million and my friend starts with $9 million, and we both end up with $5 million, I am much happier than he is. Reference points and starting positions matter.

Consider the healthcare analogy. I have a “Cadillac health plan.” You have no health insurance. Health care reform is proposed that will give us all excellent health care coverage, covering virtually every medically necessary expense we can have with minimal out-of-pocket expenses. If this passes, from my perspective, I have lost the best of all possible worlds even though the new coverage is essentially the same world. You are happy. I am not.

Most of us are familiar with the concept of loss aversion. Since being introduced by Kahneman and Tversky, the concept has seeped into the collective consciousness. Simply stated, we feel the pain of loss much more deeply than the happiness of gain. If I offer 2 tickets, one with a guaranteed win of $500 and one with a 50/50 chance of winning $1000 or nothing, most will choose the guaranteed win. If I offer 2 tickets, one with a guaranteed loss of $500 and one with a 50/50 chance of losing $1000 or no loss, most people will take the chance to avoid the guaranteed loss of $500.

If I offer to flip a coin with you, and heads you win $1000 and tails you pay me $1000, you will not take that bet. Our loss aversion is so high, that it requires winning about $2000 to overcome the loss aversion.

If I have Cadillac health plan, or even a standard employer-based plant, I am so concerned that changing to a universal plan will result in some kind of loss to me, I am inclined to fight vigorously to avoid that chance. Here again, proponents of the status quo will foment fear, uncertainty, and doubt. Fear, uncertainty, and doubt amplify the fear of loss and the resistance to change.

We have all become familiar the consequences of framing the argument. If, as a physician, I tell you that your chances of dying from treatment I am recommending is 10%, there is a decent chance will decline to treat. On the other, I tell you that this exact same treatment as a 90% chance of success and survival, there is a significantly greater chance that you will agree to it.

In universal healthcare debate, negatively framing the possible consequences of change are exploited ruthlessly. If I tell you that changing our health system will result in you losing the employer-based health insurance plan that you have come to depend on, you will almost certainly reject it.

If I tell you that transitioning to a universal healthcare system will result in a more comprehensive coverage plan, less of your wages going to your healthcare coverage and more going directly to you as increase wages, a vast reduction in co-pays and out-of-pocket expenses, and that you never have to worry about losing your coverage, whether or not you are too sick to stay in a job or your job for our opportunities, likely I can convince you that this is a good thing.

Alternatively, if I tell you that we will be transitioning to a system, modeled on the Canadian system or British system, and the only things you know about those systems are what you have been told in the media, relentlessly, for decades, the uncertainty and potential loss to you and your family become so overwhelming that you cannot possibly imagine accepting this option.

This dovetails with the concept of availability. If we are asked to guess how many words in the dictionary start with “R” versus have “R” in the 3^rd position, we will guess a far higher number of the former than the latter. This is because we can think of lots of words that begin with “R” very rapidly – they are “available” to us – and so we overestimate the number of words beginning with it. Similarly, if the stories that come to mind rapidly about alternative healthcare systems are of long waiting times and forgoing treatments, our minds naturally fixate on these examples. As someone who spent the last 15 years or so studying international healthcare systems, my mind rapidly goes in the opposite direction, with myriad examples of better access to care, lower costs, and so on that anchor my thinking to the benefits of other systems, rather than the potential downsides.

Finally, the sunk cost fallacy is a bit harder to envision in the universal healthcare debates, as it is well camouflaged. As a nation, we have contributed trillions of dollars to the building up of massive companies, both for-profit and nonprofit like, presuming that this investment is giving us the best possible health care system. It is not. This is not to say that our institutions are failing, quite the contrary. We have the best trained healthcare professionals in the world. We have the best medical research in the world. We have many of the best hospitals in the world. But our para-medical companies are not serving us well. They have created bloated, imperious, rapacious engines of profit, paying lip service to the primacy of patients or members or participants or providers, but legitimately only excelling at growth.

When we think of the scale of the infrastructure surrounding the administration of health insurance plans, pharmaceutical manufacturers, medical device makers, and the related supporting industries, the footprint in the economy is massive. The workforce is massive. In health plans alone there are armies of nurses and doctors and support staff and administrators supporting them, whose sole task is called “utilization management,” what the rest of the world knows as the “approval/denial people.” In the trenches of the opposing armies, are their counterpart nurses and doctors and support staff and administrators working for hospitals or clinics or doctors’ offices, engaged in daily battle over whether the member/patient is “eligible” for the treatment or payment being sought.

Wendell Potter has pointed out that, “Health insurers have been successful at two things: Making money and getting the American public to believe they’re essential.” They will not go quietly into that good night. There is too much money on the line. Never mind that most of it adds no value to the health care system (i.e., it is waste), it is a robustly reliable revenue stream.

“One man’s waste is another man’s revenue.”

Well, that is all very grim. What is the solution?

My proposal is to use both system 1 and system 2 thinking to show the clear advantages of transitioning to a universal healthcare system in America. I am not talking about “gaming” the American psyche, I am talking about de-programming it from decades of misinformation propagated by the special interests that continue to literally and figuratively make a killing off of healthcare in America.

Continued in part 2. (When I get to it!)

Recommended reading:

Lewis, M. (2016). The undoing project: A friendship that changed the world. Penguin UK.

Rosenthal, E. (2018). An American Sickness: How Health Care Became Big Business and How You Can Take It Back. Missouri Medicine, 115(2), 128.

Reinhardt, U. E. (2019). Priced Out: The Economic and Ethical Costs of American Health Care. Princeton University Press.

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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

Uwe E. Reinhardt

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 how to 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 why we 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?

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