Death By Anecdote, Part 2

Please read the first part of this article.

When a story is false, we run into a third problem: Even when misinformation is corrected, many people continue to believe it. For example, in one study, participants from Australia, Germany and the United States were asked about arguments made by the US government favoring the invasion of Iraq which were subsequently retracted, such as the claim that Iraq possessed weapons of mass destruction (WMDs). The Australian and German students were sensitive to retraction; that is, when they knew a claim had been retracted, they tended not to believe it. The Americans, however, were insensitive to retraction; on the whole, they tended to believe statements that they knew had been retracted about as much as statements they did not know had been retracted.

Paradoxically, attempts to correct misinformation can lead to a backfire effect, in which people are more likely to believe false information after it has been debunked. Sometimes this is due to increased familiarity with the claim as a result of its being repeated during the retraction. However, backfire effects are most likely to occur when the original claim is consistent with the ideology of the person who believes it. Not surprisingly, Republicans were more likely than Democrats to continue to believe that Iraq had WMDs even after the Bush administration admitted they didn't. When ideological backfire effects occur, people can be suspicious of the motives of the person or organization doing the correcting (often the news media) and discount the retraction.

Lewandowsky and others make three suggestions for successfully correcting misinformation: (1) warn people at the time of initial exposure that the information is suspect, (2) repeat the retraction several times, focusing only on the new, correct information, and (3) provide a plausible alternative explanation for the previous false belief. In the case of ideologically motivated false beliefs, they make a fourth recommendation: Affirm the target's ideology before attempting to correct the false belief. The first two remedies require news media cooperation that the Obama administration is unlikely to receive. Since no single alternative explanation accounts for all the anti-ACA anecdotes, providing plausible explanations for false beliefs requires extensive investigation of individual cases. The fourth suggestion would seem to require a statement like this: “We agree with you that Obamacare is a disaster, but in this case, you are wrong because . . .” 

Here is Lewandowsky discussing misinformation and its correction in the important area of climate change.

I see no magic bullet here. The best solution for the administration may be to appeal to the value Americans place on self-reliance and encourage them to explore their health care options for themselves. But they can't do that until their website is fixed. If they lose the cooperation of young people, the market will suffer from adverse selection—not enough people paying into the system, and too many older, sicker people drawing it down. Insurance rates could increase dramatically next year, just in time for the 2014 elections. Then Obama will see how much fun it would be if the Tea Party controlled the Senate as well as the House.

The HealthCare.gov fiasco is bad news for single payer advocates too. I'm afraid most people don't realize that it was Obama's reliance on an "overly-complicated, market-based Republican health care plan" that made the website so difficult to set up. They may simply conclude that government can't do anything right.

You may also be interested in reading:

Death By Anecdote, Part 1

Policy By Anecdote

Climate of Mistrust

Death By Anecdote, Part 1

You can lie with statistics, but a well-chosen anecdote is much more effective.

Here's something to look forward to, right along with your next colonoscopy.  The New York Times reports that the Republican Party plans to carry out a sustained, organized attack on the Affordable Care Act (ACA) for the next year, in the hope of gaining an advantage in the 2014 elections. The Republican campaign, described as a “multilayered sequenced assault,” is outlined in the House Republican Playbook, a 17-page strategy document prepared by their House leadership. It lists a series of talking points such as: “Because of Obamacare, I lost my insurance,” “Obamacare increases health care costs,” and “The exchanges may not be secure, putting personal information at risk.” House members are advised to collect anecdotes from constituents in support of these talking points through social media, letters and visits to their home distract. A new website, gop.gov/yourstory, centralizes the collection of these anecdotes. Republicans are instructed in the use of “messaging tools” for disseminating the stories, for example, a sample op-ed for submitting to local newspapers.

The idea is to flood the media with anecdotes in support of a particular talking point. If there is an effective counterresponse from Democrats, they will shift immediately to a different talking point. Topics waiting in the wings for possible use include insurance “rate shocks,” threats to being able to keep your doctor, and possible changes to Medicare Advantage policies.

The Republicans recognize that anecdotes can have a powerful influence on public opinion. When making inferences, people use judgmental heuristics, or mental shortcuts to make decisions quickly and easily. The use of heuristics is automatic and unconscious.  They usually lead to correct inferences, but they sometimes lead us astray.

One inference we often make is to estimate the size of a category or the frequency of an event. For example, how many Americans are being harmed by the ACA? The availability heuristic suggests that the size of a category is judged by the ease with which examples can be brought to mind. Examples are more easily retrieved from memory if they are concrete rather than abstract, if they are dramatic and interesting, or if they happened recently or nearby. Personal experiences are particularly salient. When people are asked to estimate the frequency of various causes of death, they overestimate homicides and auto accidents, but underestimate strokes and diabetes. Clearly, their estimates are influenced by media coverage.

The problem gets worse when you consider the base rate fallacy, which states that people are inattentive to population statistics, and their judgments are not sufficiently affected by them. In one study, participants were given vivid stories about misbehavior by prison guards or welfare recipients. Attitudes toward these groups were equally negatively affected regardless of whether they were told that the anecdotes were typical of the population, not typical of the population, or they were given no base rate information. In another study, college students' intentions to take courses were affected by single brief face-to-face comments from a stranger, but hardly at all by statistical summaries of the course evaluations of much larger numbers of students who had previously taken the course.

The availability heuristic and the base rate fallacy suggest that even if people are given accurate information suggesting than the story is unrepresentative, their false impression is unlikely to be corrected. There was heavy media coverage of the first wave of anecdotes from people who claimed that their insurance costs went up due to Obamacare.  When critics examined them more closely, many of these anecdotes were found to be misleading. Insurance companies cancelled policies and raised rates long before the ACA. The percentage of people whose policies were cancelled was small. Some of these people were able to get equal or better insurance through the exchanges without paying more. However, the corporate media can't be counted on to investigate anecdotes before airing them, and the debunking stories seldom receive anywhere near the attention given to the original report.

The Obama administration has apparently decided that the best defense is a good offense, so they are responding with anecdotes of their own—so-called Obamacare “success stories.” While this may be the best they can do under the circumstances, they are unlikely to get much cooperation from the corporate media in publicizing these stories. The media don't cover successful airplane landings--unless you land it in the Hudson River. Meanwhile, the administration and the media have largely overlooked another potential source of much more tragic stories: the 5.2 million people who are being denied health insurance entirely because they happen to live in states where Republican governors and legislatures have blocked Medicaid expansion. But to the corporate media, an upper middle class person losing a few dollars a month is much more newsworthy than a poor person losing his or her life.

But remember, the plural of anecdote is not data. To be continued.

You may also be interested in reading:

Death By Anecdote, Part 2

Policy By Anecdote

The Coverage Gap:  The Real Failure of Obamacare

Sen. Jim Ferlo Luncheon on Medicare and Social Security.

Please Join
STATE SENATOR JIM FERLO

PA Alliance for Retired Americans
& Western PA Coalition for Single Payer Health Care
for a luncheon to discuss the need to protect Social Security and Medicare.
Friday • December 6, 2013 • 12 Noon
Wyndham Pittsburgh University Center • 100 Lytton Avenue • Oakland
Limited Seating, Registration Required.
Please call 412-621-3006 or email dlang@pasenate.com
Please bring a new, unwrapped toy to donate to Toys for Tots.
Toys will be collected by volunteers from the Marine Corps League!
LUNCHEON FORUM
Keep Social Security & Medicare Off
the Federal Budget Chopping Block!
What is happening to our great nation? The middle class is vanishing, and
income inequality is the worst in our nation’s history. Many people work their
whole lives but have too little or no retirement savings. Proposals in
Washington call for short and long term benefit reductions to both Social
Security and Medicare. The 14th Congressional District could lose over $4
million in benefits for seniors in 2015 alone! Enacting the proposed changes
will hurt older people, local economies, women, and the disabled in greater
proportion. Join us to hear from experts who will dispute the myths, and join
with advocates who are fighting back against balancing the federal deficit on
the backs of those most in need of these cherished federal programs.
GUEST SPEAKERS
Senator Jim Ferlo — Chairman
Leo Gerard — President, United Steelworkers of America
Prof. Wayne Burton — President, PA Alliance for Retired Americans
Nicole Woo — Center for Economic and Policy Research
Andrew Coates MD, FACP — President, Physicians for A National Health Program
Ed Grystar — Western PA Coalition for Single Payer Health Care
“No Grand Bargain”

The Slides from the Friedman Talk

Pennsylvania single payer november 2013 131103 from University of Pittsburgh

For those of you who missed the talk by Economist Friedman last Tuesday on the economic impact study, you can now see the slides from his presentation.  Video if his Pittsburgh talk will be forthcoming.  His talk in Lancaster at Franklin & Marshall College will be shown on PCNTV at 9 this evening and 11am tomorrow, Tuesday Nov. 25.  It will be livestreamed on their website Here.

Are You Feeling Lonely?

Outlier (noun): (1) a person whose residence and place of business are at a distance; (2) something (as a geological feature) that is situated away from or classed differently from a main or related body; (3) a statistical observation that is markedly different in value from the others of the sample.

The Organization for Economic Cooperation and Development (OECD) has released Health at a Glance, its 2013 report on the performance of health systems in its member nations. Here is one of the charts.

The vertical dimension is life expectancy in years. On the horizontal is health care spending per person in US dollars. The line is the curve which best fits the data. It has both a linear component—as health care spending goes up, life expectancy increases—and a quadratic component—as spending increases, each dollar spent has diminishing returns. The United States is an outlier. We are spending quite a bit more (about $2400 per person more) than any other country, but our life expectancy is 26^th out of the 40 countries, almost one year lower than the international average. Another way of looking at it is that the two countries closest to us in life expectancy, Chile and the Czech Republic, are spending less than a quarter of what we're spending per capita on health care.

We're spending lots of money, but not getting a good return on our investment. A substantial portion of the money is being spent not on improved health care services, but rather on ever higher profits for private insurers, drug companies, and giant hospital chains.

The next time a politician says we have “the best health care system in the world,” you are free to burst out laughing.

You may also be interested in reading:

Where's the Outrage?

Why Are American Health Care Costs So High?

An Activist Interview

Fighting the Good Fight from BillMoyers.com on Vimeo.

It was a great talk by Dr. Friedman last night with a large crowd of 70. The outrage was definitely there.  A video by Julie Sokolow will be forthcoming of the talk. Posted here is an interview with former Green Party Presidential Candidate Jill Stein and Physician Margaret Flowers on how to use the information gained from researchers like Friedman and this site.  

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Ferlo's Inspirational Speech on Single Payer

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Where's the Outrage?

Drs. Peter Ubel, Amy Abernethy and Yousuf Zafar, all medical doctors, published an editorial in The New England Journal of Medicine entitled “Full Disclosure—Out-of-Pocket Costs as Side Effects.” An abbreviated version by Dr. Ubel appeared as an op-ed in The New York Times as “Doctor, First Tell Me What It Costs.” They argue that, just as doctors typically discuss negative side effects of drugs and medical treatments with their patients, they should also discuss the financial cost of drugs and medical treatments before the patient makes a decision. These costs should be treated as a potential side-effects because stress from the threat of financial ruin can adversely affect the patient's health. They note that cost is sometimes not discussed because both patients and doctors are too embarrassed to bring it up.

Some examples of costly decisions are given.

• Bevacizumab (or Avastin), a drug which extends the lives of colorectal cancer sufferers an average of five months beyond chemotherapy alone, has a median price of $44,000. A patient on Medicare would be responsible for 20% of that cost, or $8800.

• A breast cancer patient with a high deductible health insurance policy faces average out-of-pocket costs of $55,000—obviously, more than the life savings of most Americans. A person with a high deductible plan faces a bill of $40,000 for myocardial infarction, and $4,000 per year for management of “uncomplicated” diabetes. (Meanwhile employers are increasingly shifting workers to insurance policies with higher co-payments and deductibles.)

The authors state four reasons it would be beneficial for doctors to inform patients in advance of the cost of treatment. My comments on each are in parentheses.

1. Informing the patient of the cost of treatment may cause some patients to switch to a less expensive alternative treatment that is just as effective. (Why would a doctor ever recommend a drug or treatment if there is an equally effective and less expensive alternative?)
2. Some patients may be “willling to trade off some chance of medical benefit” in exchange for lower cost. (This possibility, which the authors refer to as “complex and ethically charged,” gets to the heart of the matter. Some patients may choose to forego treatment rather than leave themselves or their families bankrupt. It is implied that knowing the full cost of treatment may persuade some folks to commit passive suicide.)
3. Patients could attempt to obtain financial assistance in advance of the treatment. (An example is given of someone who was able to obtain help from a charity—a rare event, at best.)
4. “A growing body of evidence” suggests that if patients take cost into account, it “might reduce costs for patients and society in the long term.” (However, there is no citation to this body of evidence and the authors do not elaborate. They may mean that if everyone became more cost-conscious, prices might come down, but does the health care industry operate the same way as other more competitive markets?)

It seems so obvious that doctors should discuss costs with patients that it hardly seems necessary for NEJM to publish an editorial suggesting that they do so. But the most revealing thing about this article is the issues Ubel and his colleagues don't even mention.

First of all, they don't ask why the costs of drugs and medical treatment are so much higher in this country than in other industrialized countries. Medical costs are treated as if they were merely an uncontroversial feature of the natural environment, and no mention is made of how they might be reduced.

My colleague Paul Ricci has blogged frequently—for example, here—about how we're spending much more per person on health care than other countries, and getting mediocre results. Ezra Klein has posted 21 graphs with comparative data on the costs of specific drugs and medical treatments. Medical bills account for over 60% of U. S., bankruptcies, and 75% of people with medically-related bankruptcies had health insurance.  A 2013 survey of 11 countries by the Commonwealth Fund found that Americans were more likely than residents of the other ten countries to forego health care because of cost and to have difficult paying for care even when they were insured.

There is some objective data comparing the causes of our higher prices. A 2012 study by the Institute of Medicine, a division of the National Academy of Sciences, estimated that the U. S. health care system wastes $750 billion a year, roughly 30% of the money spent. The report identified six major areas of waste: unnecessary services ($210 billion annually), inefficient delivery of care ($130 billion), excess administrative costs ($190 billion), inflated prices ($105 billion), prevention failures ($55 billion), and fraud ($75 billion). Our doctors are more highly compensated than doctors in the rest of the world. Our hospitals attempt to maximize their profits, regardless of whether they are legally registered as for-profit or nonprofit corporations. Part of the problem is political corruption. For example, when Congress expanded Medicare to include prescription drug coverage, Medicare was forbidden to use its purchasing power to negotiate for lower drug prices.

More importantly, the authors don't even question why it is necessary for so many Americans to choose between financial ruin and illness or death when they suffer from common medical conditions. They fail to mention that the rest of the world's developed countries have largely solved this dilemma by establishing government run single payer health care systems. If this were merely a matter of money, we could talk about the vast sums this country wastes on overseas military misadventures, or the way our billionaires grow increasingly rich while paying lower tax rates than their secretaries. But these outrages are irrelevant, since a single payer system will save money. All the countries with single payer spend less per capita on health care than we do.

To be fair, Ubel does say, “No one should have to suffer unnecessarily from the cost of medical care.” But he fails to pursue any of the implications of this remark. The authors never make the point that single payer would almost certainly solve many of the financial problems they agonize over in these articles. I suppose it's possible Ubel and his colleagues are secretly hoping to build momentum for single payer by encouraging doctors to empathize more with their patients, but there's nothing in the article to support this speculation.

To paraphrase a point frequently made by Noam Chomsky, no one becomes a tenured professor at an elite university, or is invited to write an editorial for The New York Times, unless he or she has completely internalized the world view of the ruling class, and in the process learned to ignore all the really important issues facing our society.

You may also be interested in reading:

Why Are American Health Care Costs So High?

New Time Magazine Article on Health Care Costs

Protecting the Parasites:  The Irony of Obamacare

Reminder for Save Dollars, Save Lives with Economist Gerald Friedman

The antics of the Affordable Care Act rollout are spoofed in this cartoon by Tom Tomorrow.

There is an alternative to what Democrats and Republicans are proposing. On Tuesday, Nov. 19 Dr. Gerald Friedman will present his economic impact study (EIS) on how a single payer system would be more efficient in providing care and controlling costs for Pennsylvania.  An executive summary of his study can be read here and the full can be read here.  Below is a video of him discussing his study for the state of Maryland.

**Related Posts** 

State of Working PA: Slowing Job Growth, Falling Wages Impede Recovery (and The Drop in Uninsured)

Economic Impact Study Press Release

The Affordable Care Act Having an Impact in Some States but not Pennsylvania

Conceptualizing Health Care Policy

Mike Konczal has written an important article in which he asks: (1) What parts the Affordable Care Act (ACA) are not working well, and why?, and (2) What does this imply about future developments in health care policy? Will government abandon the effort to provide health care for all, or will we move toward a single-payer system?

Paul Krugman has described the ACA as a “kludge.” It is too complicated, and those complications are making the system inefficient and expensive, while depriving many Americans of health insurance. Konczal notes four specific problems:

1. The process of signing up for health insurance in the federal exchange (HealthCare.gov) is complicated because everyone must be means tested. The government must be able to confirm virtually every datum the applicants enter: their identity, their citizenship, their income, their eligibility for coverage through other federal or state programs, etc. All this is necessary to determine whether each applicant is entitled to a subsidy, and if so, the amount.
2. A further complication is that each applicant must be matched to a private insurer. The government must check that all of the thousands of insurance plans meet their minimum standards. They must clearly communicate the important characteristics of each policy to consumers, even though the insurance companies deliberately try to confuse them. They must contend with insurance company sabotage such as canceling plans abruptly and arbitrarily raising rates.
3. The ACA faces the threat of adverse selection—the possibility that the oldest and sickest among us will patiently navigate the exchange and eventually purchase a policy, while the youngest and healthiest will ignore the law and hope the penalty for not buying insurance is unenforceable. If Americans in poor health are more likely to buy insurance, the costs go up and there is a very real possibility that the system will collapse.
4. Finally, the federal government has to deal with attempted sabotage by states controlled by Republican governors and legislatures, exemplified by their refusal to set up state exchanges and to participate in Medicaid expansion, which is denying coverage to over 5 million low income Americans.

Summarizing these problems, Konczal describes two approaches to social insurance, which he calls Category A and Category B.

Konczal describes Category A as the “neoliberal” approach to public policy. Neoliberalism has, in recent years, become a synonym for conservatism. It refers to policies that reduce the role of government in public life through strategies such as privatization and deregulation. Category A social insurance sees the government as “an enabler to market activities, with perhaps some coordinated charity to individuals most in need.”

Category B, on the other hand, encompasses progressive programs such as the New Deal and the Great Society. It sees certain goods and services, such as food, shelter and health care, as basic human rights, and attempts to remove them from the marketplace by providing them to everyone.

There are very few pure examples of Categories A and B; most policies fall somewhere along a continuum between these extremes. However, the ACA falls clearly into Category A. This is not surprising because it is a plan devised by a conservative think tank which was promoted for decades by the Republican party. Social Security and Medicare, on the other hand, fall into Category B. Medicaid is a hybrid, since it is means tested and administered (and regularly sabotaged) by the states.

In the last three decades, we have seen a gradual rollback of Category B programs. This is not surprising, given the extent to which the political system is controlled by corporations and wealthy individuals. In the old days, the Republicans favored Category A and the Democrats Category B. As both parties have shifted to the right, the Democrats have shifted their allegiance to the Category A policies favored by their corporate donors, while many Republicans advocate eliminating social insurance entirely.

Whenever a public service is privatized, it moves from Category B to A. This is what happens, for example, when you turn over tax dollars to charter schools, so that corporations can make profits by educating children as cheaply as possible. Of course, the ultimate disaster for the country would be the Republican plan to privatize Social Security, since another Great Recession—a virtual certainty in the absence of financial reregulation—would have the potential to impoverish our elderly population.

PA Governor Tom Corbett's proposal to expand Medicaid would move this program further toward Category A through a combination of stricter means testing and turning the program over to private insurance companies. Our President, Dave Steil, has written an op-ed critizing the Corbett plan. He rightly notes the waste of money that would result from turning Medicaid over to private insurance companies. However, he overlooks the hardship that increased means testing, premiums and copayments will impose on working class Pennsylvanians.

Advocates of single payer health insurance—obviously a Category B program—are going to be urinating into a stiff wind for the foreseeable future. However, there is some hope. It is the four Category A characteristics noted above that are turning the ACA into a “kludge.” While Republicans will argue for repeal, pragmatists are likely to notice that if you drop some of these characteristics, you can improve health outcomes while saving money. And if you drop all four, you have single payer.

You may also be interested in reading:

The Coverage Gap:  The Real Failure of Obamacare

A Clouded Vision, Part 1:  The Stick

A Clouded Vision, Part 2:  The Carrot

Medicaid, Medical Insurance, Health Care and the Corbett Plan