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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