Why Facts Don’t Change Our Minds

In 1975, researchers at Stanford invited a group of undergraduates to take part in a study about suicide. They were presented with pairs of suicide notes. In each pair, one note had been composed by a random individual, the other by a person who had subsequently taken his own life. The students were then asked to distinguish between the genuine notes and the fake ones.

Some students discovered that they had a genius for the task. Out of twenty-five pairs of notes, they correctly identified the real one twenty-four times. Others discovered that they were hopeless. They identified the real note in only ten instances.

As is often the case with psychological studies, the whole setup was a put-on. Though half the notes were indeed genuine—they’d been obtained from the Los Angeles County coroner’s office—the scores were fictitious. The students who’d been told they were almost always right were, on average, no more discerning than those who had been told they were mostly wrong.

In the second phase of the study, the deception was revealed.

The students were told that the real point of the experiment was to gauge their responses to thinking they were right or wrong. (This, it turned out, was also a deception.) Finally, the students were asked to estimate how many suicide notes they had actually categorized correctly, and how many they thought an average student would get right. At this point, something curious happened. The students in the high-score group said that they thought they had, in fact, done quite well—significantly better than the average student—even though, as they’d just been told, they had zero grounds for believing this. Conversely, those who’d been assigned to the low-score group said that they thought they had done significantly worse than the average student—a conclusion that was equally unfounded.

“Once formed,” the researchers observed dryly, “impressions are remarkably perseverant.”

A few years later, a new set of Stanford students was recruited for a related study. The students were handed packets of information about a pair of firefighters, Frank K. and George H. Frank’s bio noted that, among other things, he had a baby daughter and he liked to scuba dive. George had a small son and played golf. The packets also included the men’s responses on what the researchers called the Risky-Conservative Choice Test. According to one version of the packet, Frank was a successful firefighter who, on the test, almost always went with the safest option. In the other version, Frank also chose the safest option, but he was a lousy firefighter who’d been put “on report” by his supervisors several times. Once again, midway through the study, the students were informed that they’d been misled, and that the information they’d received was entirely fictitious. The students were then asked to describe their own beliefs. What sort of attitude toward risk did they think a successful firefighter would have? The students who’d received the first packet thought that he would avoid it. The students in the second group thought he’d embrace it.

Even after the evidence “for their beliefs has been totally refuted, people fail to make appropriate revisions in those beliefs,” the researchers noted. In this case, the failure was “particularly impressive,” since two data points would never have been enough information to generalize from.

The Stanford studies became famous. Coming from a group of academics in the nineteen-seventies, the contention that people can’t think straight was shocking. It isn’t any longer. Thousands of subsequent experiments have confirmed (and elaborated on) this finding. As everyone who’s followed the research—or even occasionally picked up a copy of Psychology Today—knows, any graduate student with a clipboard can demonstrate that reasonable-seeming people are often totally irrational. Rarely has this insight seemed more relevant than it does right now. Still, an essential puzzle remains: How did we come to be this way?

In a new book, “The Enigma of Reason” (Harvard), the cognitive scientists Hugo Mercier and Dan Sperber take a stab at answering this question. Mercier, who works at a French research institute in Lyon, and Sperber, now based at the Central European University, in Budapest, point out that reason is an evolved trait, like bipedalism or three-color vision. It emerged on the savannas of Africa, and has to be understood in that context.

Stripped of a lot of what might be called cognitive-science-ese, Mercier and Sperber’s argument runs, more or less, as follows: Humans’ biggest advantage over other species is our ability to coöperate. Coöperation is difficult to establish and almost as difficult to sustain. For any individual, freeloading is always the best course of action. Reason developed not to enable us to solve abstract, logical problems or even to help us draw conclusions from unfamiliar data; rather, it developed to resolve the problems posed by living in collaborative groups.

“Reason is an adaptation to the hypersocial niche humans have evolved for themselves,” Mercier and Sperber write. Habits of mind that seem weird or goofy or just plain dumb from an “intellectualist” point of view prove shrewd when seen from a social “interactionist” perspective.

Consider what’s become known as “confirmation bias,” the tendency people have to embrace information that supports their beliefs and reject information that contradicts them. Of the many forms of faulty thinking that have been identified, confirmation bias is among the best catalogued; it’s the subject of entire textbooks’ worth of experiments. One of the most famous of these was conducted, again, at Stanford. For this experiment, researchers rounded up a group of students who had opposing opinions about capital punishment. Half the students were in favor of it and thought that it deterred crime; the other half were against it and thought that it had no effect on crime.

The students were asked to respond to two studies. One provided data in support of the deterrence argument, and the other provided data that called it into question. Both studies—you guessed it—were made up, and had been designed to present what were, objectively speaking, equally compelling statistics. The students who had originally supported capital punishment rated the pro-deterrence data highly credible and the anti-deterrence data unconvincing; the students who’d originally opposed capital punishment did the reverse. At the end of the experiment, the students were asked once again about their views. Those who’d started out pro-capital punishment were now even more in favor of it; those who’d opposed it were even more hostile.

If reason is designed to generate sound judgments, then it’s hard to conceive of a more serious design flaw than confirmation bias. Imagine, Mercier and Sperber suggest, a mouse that thinks the way we do. Such a mouse, “bent on confirming its belief that there are no cats around,” would soon be dinner. To the extent that confirmation bias leads people to dismiss evidence of new or underappreciated threats—the human equivalent of the cat around the corner—it’s a trait that should have been selected against. The fact that both we and it survive, Mercier and Sperber argue, proves that it must have some adaptive function, and that function, they maintain, is related to our “hypersociability.”

Mercier and Sperber prefer the term “myside bias.” Humans, they point out, aren’t randomly credulous. Presented with someone else’s argument, we’re quite adept at spotting the weaknesses. Almost invariably, the positions we’re blind about are our own.

A recent experiment performed by Mercier and some European colleagues neatly demonstrates this asymmetry. Participants were asked to answer a series of simple reasoning problems. They were then asked to explain their responses, and were given a chance to modify them if they identified mistakes. The majority were satisfied with their original choices; fewer than fifteen per cent changed their minds in step two.

In step three, participants were shown one of the same problems, along with their answer and the answer of another participant, who’d come to a different conclusion. Once again, they were given the chance to change their responses. But a trick had been played: the answers presented to them as someone else’s were actually their own, and vice versa. About half the participants realized what was going on. Among the other half, suddenly people became a lot more critical. Nearly sixty per cent now rejected the responses that they’d earlier been satisfied with.

This lopsidedness, according to Mercier and Sperber, reflects the task that reason evolved to perform, which is to prevent us from getting screwed by the other members of our group.

Living in small bands of hunter-gatherers, our ancestors were primarily concerned with their social standing, and with making sure that they weren’t the ones risking their lives on the hunt while others loafed around in the cave. There was little advantage in reasoning clearly, while much was to be gained from winning arguments.

Among the many, many issues our forebears didn’t worry about were the deterrent effects of capital punishment and the ideal attributes of a firefighter. Nor did they have to contend with fabricated studies, or fake news, or Twitter. It’s no wonder, then, that today reason often seems to fail us. As Mercier and Sperber write, “This is one of many cases in which the environment changed too quickly for natural selection to catch up.”

Steven Sloman, a professor at Brown, and Philip Fernbach, a professor at the University of Colorado, are also cognitive scientists. They, too, believe sociability is the key to how the human mind functions or, perhaps more pertinently, malfunctions. They begin their book, “The Knowledge Illusion: Why We Never Think Alone” (Riverhead), with a look at toilets.

Virtually everyone in the United States, and indeed throughout the developed world, is familiar with toilets. A typical flush toilet has a ceramic bowl filled with water. When the handle is depressed, or the button pushed, the water—and everything that’s been deposited in it—gets sucked into a pipe and from there into the sewage system. But how does this actually happen?

In a study conducted at Yale, graduate students were asked to rate their understanding of everyday devices, including toilets, zippers, and cylinder locks. They were then asked to write detailed, step-by-step explanations of how the devices work, and to rate their understanding again. Apparently, the effort revealed to the students their own ignorance, because their self-assessments dropped. (Toilets, it turns out, are more complicated than they appear.)

Sloman and Fernbach see this effect, which they call the “illusion of explanatory depth,” just about everywhere. People believe that they know way more than they actually do. What allows us to persist in this belief is other people. In the case of my toilet, someone else designed it so that I can operate it easily. This is something humans are very good at. We’ve been relying on one another’s expertise ever since we figured out how to hunt together, which was probably a key development in our evolutionary history. So well do we collaborate, Sloman and Fernbach argue, that we can hardly tell where our own understanding ends and others’ begins.

“One implication of the naturalness with which we divide cognitive labor,” they write, is that there’s “no sharp boundary between one person’s ideas and knowledge” and “those of other members” of the group.

This borderlessness, or, if you prefer, confusion, is also crucial to what we consider progress. As people invented new tools for new ways of living, they simultaneously created new realms of ignorance; if everyone had insisted on, say, mastering the principles of metalworking before picking up a knife, the Bronze Age wouldn’t have amounted to much. When it comes to new technologies, incomplete understanding is empowering.

Where it gets us into trouble, according to Sloman and Fernbach, is in the political domain. It’s one thing for me to flush a toilet without knowing how it operates, and another for me to favor (or oppose) an immigration ban without knowing what I’m talking about. Sloman and Fernbach cite a survey conducted in 2014, not long after Russia annexed the Ukrainian territory of Crimea. Respondents were asked how they thought the U.S. should react, and also whether they could identify Ukraine on a map. The farther off base they were about the geography, the more likely they were to favor military intervention. (Respondents were so unsure of Ukraine’s location that the median guess was wrong by eighteen hundred miles, roughly the distance from Kiev to Madrid.)

Surveys on many other issues have yielded similarly dismaying results. “As a rule, strong feelings about issues do not emerge from deep understanding,” Sloman and Fernbach write.

And here our dependence on other minds reinforces the problem. If your position on, say, the Affordable Care Act is baseless and I rely on it, then my opinion is also baseless. When I talk to Tom and he decides he agrees with me, his opinion is also baseless, but now that the three of us concur we feel that much more smug about our views. If we all now dismiss as unconvincing any information that contradicts our opinion, you get, well, the Trump Administration.

“This is how a community of knowledge can become dangerous,” Sloman and Fernbach observe. The two have performed their own version of the toilet experiment, substituting public policy for household gadgets. In a study conducted in 2012, they asked people for their stance on questions like: Should there be a single-payer health-care system? Or merit-based pay for teachers? Participants were asked to rate their positions depending on how strongly they agreed or disagreed with the proposals. Next, they were instructed to explain, in as much detail as they could, the impacts of implementing each one. Most people at this point ran into trouble. Asked once again to rate their views, they ratcheted down the intensity, so that they either agreed or disagreed less vehemently.

Sloman and Fernbach see in this result a little candle for a dark world. If we—or our friends or the pundits on CNN—spent less time pontificating and more trying to work through the implications of policy proposals, we’d realize how clueless we are and moderate our views. This, they write, “may be the only form of thinking that will shatter the illusion of explanatory depth and change people’s attitudes.”

One way to look at science is as a system that corrects for people’s natural inclinations. In a well-run laboratory, there’s no room for myside bias; the results have to be reproducible in other laboratories, by researchers who have no motive to confirm them. And this, it could be argued, is why the system has proved so successful. At any given moment, a field may be dominated by squabbles, but, in the end, the methodology prevails. Science moves forward, even as we remain stuck in place.

In “Denying to the Grave: Why We Ignore the Facts That Will Save Us” (Oxford), Jack Gorman, a psychiatrist, and his daughter, Sara Gorman, a public-health specialist, probe the gap between what science tells us and what we tell ourselves. Their concern is with those persistent beliefs which are not just demonstrably false but also potentially deadly, like the conviction that vaccines are hazardous. Of course, what’s hazardous is not being vaccinated; that’s why vaccines were created in the first place. “Immunization is one of the triumphs of modern medicine,” the Gormans note. But no matter how many scientific studies conclude that vaccines are safe, and that there’s no link between immunizations and autism, anti-vaxxers remain unmoved. (They can now count on their side—sort of—Donald Trump, who has said that, although he and his wife had their son, Barron, vaccinated, they refused to do so on the timetable recommended by pediatricians.)

The Gormans, too, argue that ways of thinking that now seem self-destructive must at some point have been adaptive. And they, too, dedicate many pages to confirmation bias, which, they claim, has a physiological component.

They cite research suggesting that people experience genuine pleasure—a rush of dopamine—when processing information that supports their beliefs. “It feels good to ‘stick to our guns’ even if we are wrong,” they observe.

The Gormans don’t just want to catalogue the ways we go wrong; they want to correct for them. There must be some way, they maintain, to convince people that vaccines are good for kids, and handguns are dangerous. (Another widespread but statistically insupportable belief they’d like to discredit is that owning a gun makes you safer.) But here they encounter the very problems they have enumerated. Providing people with accurate information doesn’t seem to help; they simply discount it. Appealing to their emotions may work better, but doing so is obviously antithetical to the goal of promoting sound science. “The challenge that remains,” they write toward the end of their book, “is to figure out how to address the tendencies that lead to false scientific belief.”

“The Enigma of Reason,” “The Knowledge Illusion,” and “Denying to the Grave” were all written before the November election.

Thought of the Day – Having Access to People Smarter then You

Smart people aren’t your competition—they’re your secret weapons for success.

If you feel intimidated by them, it’s time to shift that mindset.

Here’s why surrounding yourself with brilliance accelerates your growth:

They challenge you to think deeper

• Their expertise becomes your knowledge

• You learn new problem-solving approaches

• Their ambition fuels your motivation

• They connect you to networks and opportunities

• You develop broader perspective on things

• Their feedback helps you improve faster

But it’s not just about what you can gain—bring something to the table, too:

• Share your unique insights and experiences

• Offer your support when they need it

• Be an active listener for their ideas

• Build trust through collaboration

• Help them connect with your own network

• Recognize and celebrate their achievements

Tap into the intelligence around you.

Your future self will thank you for the connections you make today.

Federal Reserve delivers super-sized half-point rate cut

The Federal Reserve cut its target interest rate Wednesday by an extra-large half-percentage point and projected more rate cuts this year and next, as its period of trying to put brakes on the economy to fight inflation comes to a close.

Why it matters: 

The move lowers borrowing costs for consumers and businesses, as the central bank aims to keep the economy’s expansion going strong amid warning signs on the outlook.

What they’re saying: 

“The labor market is actually in solid condition — and our intention with our policy move today is to keep it there,” Fed chair Jerome Powell told reporters at a press conference on Wednesday.

  • “The U.S. economy is in good shape. It’s growing at a solid pace,” Powell added. “We want to keep it there.”

Zoom in: 

The rate cut reflects the U.S. entering a new phase where the softening job market is the predominant economic risk — rather than elevated inflation.

  • By going with an aggressive half-point cut instead of its more traditional quarter-point adjustment, the Fed moved to get ahead of some evident faltering in the job market.
  • However, new projections imply the Fed will shift toward smaller quarter-point rate cuts from here.
  • The cut also thrusts the Fed into election-year politics, as former President Trump has said the central bank should not ease monetary policy mere weeks before the election. Some Democrats have called for even more aggressive rate cuts.

Driving the news: 

The policy-setting Federal Open Market Committee lowered its target range for the federal funds rate to 4.75%–5%, from the 5.25–5.5% range in place since last July.

  • The central bank also released new projections that anticipated the rate will be cut an additional half-point by December — implying a quarter-point cut at each of its two remaining 2024 meetings.
  • The median Fed officials anticipated their target rate will be down to 3.4% by the end of 2025, which implies four quarter-point rate cuts next year.
  • “Job gains have slowed,” the Fed’s policy statement noted, adding that the committee “has gained greater confidence that inflation is moving sustainably toward 2 percent.”

Of note: 

The Fed policy meeting marked the first dissent from a board member in more than two years. Michelle Bowman, a Trump-appointed governor who focuses on community banking issues, preferred to cut by only a quarter point.

  • Bowman’s dissent is also the first by a member of the Fed’s seven-member Board of Governors — as opposed to a regional Fed bank president — since 2005.
  • Christopher Waller, the other Trump-appointed governor on the board, supported the action.

By the numbers: 

The median official saw inflation for the full year coming in at 2.3%, not far from the Fed’s 2% target. By contrast, in June, officials saw 2.6% inflation this year.

  • They also anticipate slightly higher unemployment. The projections listed a 4.4% unemployment rate in the final quarter of the year. That rate was 4.2% in August, up from 3.7% at the start of the year.
  • However, the Fed officials’ forecasts also imply the jobless rate leveling out at that point and being flat at 4.4% in the final months of 2025.

The bottom line: 

Powell and his colleagues elected to take more aggressive action Wednesday in hopes that it will be enough to forestall any further deterioration in the job market of the sort seen over the last few months — and is betting that the Fed can move to a more gradualist approach from here.

  • Speaking about the larger-than-anticipated rate cut, Powell said he was pleased the Fed made a strong start in lowering interest rates.
  • “The logic of this — both from an economic standpoint and also from a risk management standpoint — was clear,” Powell said.
  • He added: “We’re gonna take it meeting by meeting. … There’s no sense that the committee feels it’s in a rush to do this.”

The True Value of Experience

A giant ship’s engine broke down and no one could repair it, so they hired a Mechanical Engineer with over 30 years of experience.

He inspected the engine very carefully, from top to bottom. After seeing everything, the engineer unloaded his bag and pulled out a small hammer.

He knocked something gently. Soon, the engine came to life again. The engine has been fixed!

A week later the engineer mentioned to the ship owner that the total cost of repairing the giant ship was $20,000.

“What?!” said the owner. “You did almost nothing. Give us a detailed bill.”

The Engineer replied him “The answer is simple:”

Tap with a hammer: $2

Know where to knock and how much to knock: $19,998.

The importance of appreciating one’s expertise and experience… because those are the results of struggles, experiments and even tears.

If I do a job in 30 minutes it’s because I spent 20 years learning how to do that in 30 minutes. You owe me for the years, not the minutes.

The Four Questions Healthcare Boards must Answer

In 63 days, Americans will know the composition of the 119th Congress and the new occupants of the White House and 11 Governor’s mansions. We’ll learn results of referenda in 10 states about abortion rights (AZ, CO, FL, MD, MO, MT, NE, NV, NY, SD) and see how insurance coverage for infertility (IVF therapy) fares as Californians vote on SB 729. But what we will not learn is the future of the U.S. health system at a critical time of uncertainty.

In 6 years, every baby boomer will be 65 years of age or older. In the next 20 years, the senior population will be 22% of the population–up from 18% today. That’s over 83 million who’ll hit the health system vis a vis Medicare while it is still digesting the tsunami of obesity, a scarcity of workers and unprecedented discontent:

  • The majority of voters is dissatisfied with the status quo. 69% think the system is fundamentally flawed and in need of major change vs. 7% who think otherwise. 60% believe it puts its profits above patient care vs. 13% who disagree.
  • Employers are fed up: Facing projected cost increases of 9% for employee coverage in 2025, they now reject industry claims of austerity when earnings reports and executive compensation indicate otherwise. They’re poised to push back harder than ever.
  • Congress is increasingly antagonistic: A bipartisan coalition in Congress is pushing populist reforms unwelcome by many industry insiders i.e. price transparency for hospitals, price controls for prescription drugs, limits on private equity ownership, constraint on hospital, insurer and physician consolidation, restrictions on tax exemptions of NFP hospitals, site neutral payment policies and many more.

Fanning these flames, media characterizations of targeted healthcare companies as price gouging villains led by highly-paid CEOs is mounting: last week, it was Acadia Health’s turn courtesy of the New York Times’ investigators.

Navigating uncertainty is tough for industries like healthcare where demand s growing, technologies are disrupting how and where services are provided and by whom, and pricing and affordability are hot button issues.  And it’s too big to hide: at $5.049 trillion, it represents 17.6% of the U.S. GDP today increasing to 19.7% by 2032. Growing concern about national debt puts healthcare in the crosshairs of policymaker attention:

Per the Committee for a Responsible Federal Budget: “In the latest Congressional Budget Office (CBO) baseline, nominal spending is projected to grow from $6.8 trillion in Fiscal Year (FY) 2024 to $10.3 trillion in 2034. About 87% of this increase is due to three parts of the federal budget: Social Security, federal health care programs, and interest payments on the debt.”

In response, Boards in many healthcare organizations are hearing about the imperative for “transformational change” to embrace artificial intelligence, whole person health, digitization and more. They’re also learning about ways to cut their operating costs and squeeze out operating margins. Bold, long-term strategy is talked about, but most default to less risky, short-term strategies compatible with current operating plans and their leaders’ compensation packages. Thus, “transformational change” takes a back seat to survival or pragmatism for most.

For Boards of U.S. healthcare organizations, the imperative for transformational change is urgent: the future of the U.S. system is not a repeat of its past. But most Boards fail to analyze the future and construct future-state scenarios systematically. Lessons from other industries are instructive.

  • Transformational change in mission critical industries occurs over a span of 20-25 years. It starts with discontent with the status quo, then technologies and data that affirm plausible alternatives and private capital that fund scalable alternatives. It’s not overnight.
  • Transformational change is not paralyzed by regulatory hurdles. Transformers seek forgiveness, not permission while working to change the regulatory landscape. Advocacy is a critical function in transformer organizations.
  • Transformation is welcomed by consumers. Recognition of improved value by end-users—individual consumers—is what institutionalizes transformational success. Transformed industries define success in terms of the specific, transparent and understandable results of their work.

Per McKinsey, only one in 8 organizations is successful in fully implementing transformational change completely but the reward is significant: transformers outperform their competition three-to-one on measures of growth and effectiveness.

I am heading to Colorado Springs this weekend for the Governance Institute. There, I will offer Board leaders four basic questions.

  • Is the future of the U.S. health system a repeat of the past or something else?
  • How will its structure, roles and responsibilities change?
  • How will affordability, quality, innovation and value be defined and validated?
  • How will it be funded?

Answers to these require thoughtful discussion. They require independent judgement. They require insight from organizations outside healthcare whose experiences are instructive. They require fresh thinking.

Until and unless healthcare leaders recognize the imperative for transformational change, the system will calcify its victim-mindset and each sector will fend for itself with diminishing results. No sector—hospitals, insurers, drug companies, physicians—has all the answers and every sector faces enormous headwinds. Perhaps it’s time for a cross-sector coalition to step up with transformational change as the goal and the public’s well-being the moral compass.

PS: Last week, I caught up with Drs. Steve and Pat Gabbe in Columbus, Ohio. Having served alongside them at Vanderbilt and now as an observer of their work at Ohio State, I am reminded of the goodness and integrity of those in healthcare who devote their lives to meaningful, worthwhile work. Steve “burns with a clear blue flame” as a clinician, mentor and educator. Pat is the curator of a program, Moms2B, that seeks to alleviate Black-White disparities in infant mortality and maternal child health in Ohio. They’re great people who see purpose in their calling; they’re what make this industry worth fixing!

The Politics of Health Care and the 2024 Election

https://www.kff.org/health-policy-101-the-politics-of-health-care-and-the-2024-election/?entry=table-of-contents-introduction

Introduction

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Health policy and politics are inextricably linked. Policy is about what the government can do to shift the financing, delivery, and quality of health care, so who controls the government has the power to shape those policies. 

Elections, therefore, always have consequences for the direction of health policy – who is the president and in control of the executive branch, which party has the majority in the House and the Senate with the ability to steer legislation, and who has control in state houses. When political power in Washington is divided, legislating on health care often comes to a standstill, though the president still has significant discretion over health policy through administrative actions. And, stalemates at the federal level often spur greater action by states. 

Health care issues often, but not always, play a dominant role in political campaigns. Health care is a personal issue, so it often resonates with voters. The affordability of health care, in particular, is typically a top concern for voters, along with other pocketbook issues, And, at 17% of the economy, health care has many industry stakeholders who seek influence through lobbying and campaign contributions. At the same time, individual policy issues are rarely decisive in elections. 

Health Reform in Elections

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Health “reform” – a somewhat squishy term generally understood to mean proposals that significantly transform the financing, coverage, and delivery of health care – has a long history of playing a major role in elections. 

Harry Truman campaigned on universal health insurance in 1948, but his plan went nowhere in the face of opposition from the American Medical Association and other groups. While falling short of universal coverage, the creation of Medicare and Medicaid in 1965 under Lyndon Johnson dramatically reduced the number of uninsured people. President Johnson signed the Medicare and Medicaid legislation at the Truman Library in Missouri, with Truman himself looking on. 

Later, Bill Clinton campaigned on health reform in 1992, and proposed the sweeping Health Security Act in the first year of his presidency. That plan went down to defeat in Congress amidst opposition from nearly all segments of the health care industry, and the controversy over it has been cited by many as a factor in Democrats losing control of both the House and the Senate in the 1994 midterm elections. 

For many years after the defeat of the Clinton health plan, Democrats were hesitant to push major health reforms. Then, in the 2008 campaign, Barack Obama campaigned once again on health reform, and proposed a plan that eventually became the Affordable Care Act (ACA). The ACA ultimately passed Congress in 2010 with only Democratic votes, after many twists and turns in the legislative process. The major provisions of the ACA were not slated to take effect until 2014, and opposition quickly galvanized against the requirement to have insurance or pay a tax penalty (the “individual mandate”) and in response to criticism that the legislation contained so-called “death panels” (which it did not). Republicans took control of the House and gained a substantial number of seats in the Senate during the 2010 midterm elections, fueled partly by opposition to the ACA. 

The ACA took full effect in 2014, with millions gaining coverage, but more people viewed the law unfavorably than favorably, and repeal became a rallying cry for Republicans in the 2016 campaign. Following the election of Donald Trump, there was a high profile effort to repeal the law, which was ultimately defeated following a public backlash. The ACA repeal debate was a good example of the trade-offs inherent in all health policies. Republicans sought to reduce federal spending and regulation, but the result would have been fewer people covered and weakened protections for people with pre-existing conditions. KFF polling showed that the ACA repeal effort led to increased public support for the law, which persists today. 

Health Care and the 2024 Election

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The 2024 election presents the unusual occurrence of two candidates – current vice president Kamala Harris and former president Donald Trump – who have already served in the White House and have detailed records for comparison, as explained in this JAMA column.  With President Joe Biden dropping out of the campaign, Harris inherits the record of the current administration, but has also begun to lay out an agenda of her own.

The Affordable Care Act (Obamacare)

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While Trump failed as president to repeal the ACA, his administration did make significant changes to it, including repealing the individual mandate penalty, reducing federal funding for consumer assistance (navigators) by 84% and outreach by 90%, and expanding short-term insurance plans that can exclude coverage of preexisting conditions. 

In a strange policy twist, the Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients, with Trump saying it would cause Obamacare to be “dead” and “gone.” But, insurers responded by increasing premiums, which in turn increased federal premium subsidies and federal spending, likely strengthening the ACA. 

In the 2024 campaign, Trump has vowed several times to try again to repeal and replace the ACA, though not necessarily using those words, saying instead he would create a plan with “much better health care.” 

Although the Trump administration never issued a detailed plan to replace the ACA, Trump’s budget proposals as president included plans to convert the ACA into a block grant to states, cap federal funding for Medicaid, and allow states to relax the ACA’s rules protecting people with preexisting conditions. Those plans, if enacted, would have reduced federal funding for health care by about $1 trillion over a decade. 

In contrast, the Biden-Harris administration has reinvigorated the ACA by restoring funding for consumer assistance and outreach and by increasing premium subsidies to make coverage more affordable, resulting in record enrollment in ACA Marketplace plans and historically low uninsured rates. The increased premium subsidies are currently slated to expire at the end of 2025, so the next president will be instrumental in determining whether they get extended. Harris has vowed to extend the subsidies, while Trump has been silent on the issue.

Abortion and Reproductive Health

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The health care issue most likely to figure prominently in the general election is abortion rights, with sharp contrasts between the presidential candidates and the potential to affect voter turnout. In all the states where voters have been asked to weigh in directly on abortion so far (California, Kansas, Kentucky, Michigan, Montana, Ohio, and Vermont), abortion rights have been upheld

Trump paved the way for the US Supreme Court to overturn Roe v Wade by appointing judges and justices opposed to abortion rights. Trump recently said, “for 54 years they were trying to get Roe v Wade terminated, and I did it and I’m proud to have done it.” During the current campaign, Trump has said that abortion policy should now be left to the states. 

As president, Trump had also cut off family planning funding to Planned Parenthood and other clinics that provide or refer for abortion services, but this policy was reversed by the Biden-Harris administration. 

Harris supports codifying into federal the abortion access protections in Roe v Wade.

Addressing the High Price of Prescription Drugs and Health Care Services

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Trump has often spotlighted the high price of prescription drugs, criticizing both the pharmaceutical industry and pharmacy benefit managers. Although he kept the issue of drug prices on the political agenda as president, in the end, his administration accomplished little to contain them. 

The Trump administration created a demonstration program, capping monthly co-pays for insulin for some Medicare beneficiaries at $35. Late in his presidency, his administration issued a rule to tie Medicare reimbursement of certain physician-administered drugs to the prices paid in other countries, but it was blocked by the courts and never implemented. The Trump administration also issued regulations paving the way for states to import lower-priced drugs from Canada. The Biden-Harris administration has followed through on that idea and recently approved Florida’s plan to buy drugs from Canada, though barriers still remain to making it work in practice. 

With Harris casting the tie-breaking vote in the Senate, President Biden signed the Inflation Reduction Act, far-reaching legislation that requires the federal government to negotiate the prices of certain drugs in Medicare, which was previously banned. The law also guarantees a $35 co-pay cap for insulin for all Medicare beneficiaries, and caps out-of-pocket retail drug costs for the first time in Medicare. Harris supports accelerating drug price negotiation to apply to more drugs, as well as extending the $35 cap on insulin copays and the cap on out-of-pocket drug costs to everyone outside of Medicare.

How Trump would approach drug price negotiations if elected is unclear. Trump supported federal negotiation of drug prices during his 2016 campaign, but he did not pursue the idea as president and opposed a Democratic price negotiation plan. During the current campaign, Trump said he “will tell big pharma that we will only pay the best price they offer to foreign nations,” claiming that he was the “only president in modern times who ever took on big pharma.” 

Beyond drug prices, the Trump administration issued regulations requiring hospitals and health insurers to be transparent about prices, a policy that is still in place and attracts bipartisan support. 

Future Outlook

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Ultimately, irrespective of the issues that get debated during the campaign, the outcome of the 2024 election – who controls the White House and Congress – will have significant implications for the future direction of health care, as is almost always the case. 

However, even with changes in party control of the federal government, only incremental movement to the left or the right is the norm. Sweeping changes in health policy, such as the creation of Medicare and Medicaid or passage of the ACA, are rare in the U.S. political system. Similarly, Medicare for All, which would even more fundamentally transform the financing and coverage of health care, faces long odds, particularly in the current political environment. This is the case even though most of the public favors Medicare for All, though attitudes shift significantly after hearing messages about its potential impacts. 

Importantly, it’s politically difficult to take benefits away from people once they have them. That, and the fact that seniors are a strong voting bloc, has been why Social Security and Medicare have been considered political “third rails.” The ACA and Medicaid do not have quite the same sacrosanct status, but they may be close

The Presidential Debate will Frustrate Healthcare Voters

Tomorrow night, the Presidential candidates square off in Philadelphia. Per polling from last week by the New York Times-Siena, NBC News-Wall Street Journal, Ipsos-ABC News and CBS News, the two head into the debate neck and neck in what is being called the “chaos election.”

Polls also show the economy, abortion and immigration are the issues of most concern to voters. And large majorities express dissatisfaction with the direction the country is heading and concern about their household finances.

The healthcare system per se is not a major concern to voters this year, but its affordability is. Out-of-pocket costs for prescription drugs, insurance premiums and co-pays and deductibles for hospitals and physician services are considered unreasonable and inexplicably high. They contribute to public anxiety about their financial security alongside housing and food costs. And majorities think the government should do more by imposing price controls and limiting corporate consolidation.

That’s where we are heading into this debate. And here’s what we know for sure about the 90-minute production as it relates to health issues and policies:

  • Each candidate will rail against healthcare prices, costs, and consolidation taking special aim at price gouging by drug companies and corporate monopolies that limit competition for consumers.
  • Each will promise protections for abortion services: Trump will defer to states to arbitrate those rights while Harris will assert federal protection is necessary.
  • Each will opine to the Affordable Care Act’s future: Trump will promise its repeal replacing it “with something better” and Harris will promise its protection and expansion.
  • Each will promise increased access to behavioral health services as memories of last week’s 26-minute shooting tirade at Apalachee High School fade and the circumstances of Colt Gray’s mental collapse are studied.
  • And each will promise adequate funding for their health priorities based on the effectiveness of their proposed economic plans for which specifics are unavailable.

That’s it in all likelihood. They’re unlikely to wade into root causes of declining life expectancy in the U.S. or the complicated supply-chain and workforce dynamics of the industry. And the moderators are unlikely to ask probative questions like these to discover the candidate’s forethought on matters of significant long-term gravity…

  • What are the most important features of health systems in the world that deliver better results at lower costs to their citizens that could be effectively implemented in the U.S. system?
  • How should the U.S. allocate its spending to improve the overall health and well-being of the entire population?
  • How should the system be funded?

My take:

I will be watching along with an audience likely to exceed 60 million. Invariably, I will be frustrated by well-rehearsed “gotcha” lines used by each candidate to spark reaction from the other. And I will hope for more attention to healthcare and likely be disappointed.

Misinformation, disinformation and AI derived social media messaging are standard fare in winner-take-all politics.

When used in addressing health issues and policies, they’re effective because the public’s basic level of understanding of the health system is embarrassingly low: studies show 4 in 5 American’s confess to confusion citing the system’s complexity and, regrettably, the inadequacy of efforts to mitigate their ignorance is widely acknowledged.

Thus, terms like affordability, value, quality, not-for-profit healthcare and many others can be used liberally by politicians, trade groups and journalists without fear of challenge since they’re defined differently by every user.

Given the significance of healthcare to the economy (17.6% of the GDP),

the total workforce (18.6 million of the 164 million) and individual consumers and households (41% have outstanding medical debt and all fear financial ruin from surprise medical bills or an expensive health issue), it’s incumbent that health policy for the long-term sustainability of the health system be developed before the system collapses. The impetus for that effort must come from trade groups and policymakers willing to invest in meaningful deliberation.

The dust from this election cycle will settle for healthcare later this year and in early 2025. States are certain to play a bigger role in policymaking: the likely partisan impasse in Congress coupled with uncertainty about federal agency authority due to SCOTUS; Chevron ruling will disable major policy changes and leave much in limbo for the near-term.

Long-term, the system will proceed incrementally. Bigger players will fare OK and others will fail. I remain hopeful thoughtful leaders will address the near and long-term future with equal energy and attention.

Regrettably, the tyranny of the urgent owns the U.S. health system’s attention these days: its long-term destination is out-of-sight, out-of-mind to most. And the complexity of its short-term issues lend to magnification of misinformation, disinformation and public ignorance.

That’s why this debate will frustrate healthcare voters.

PS: Congress returns this week to tackle the October 1 deadline for passing 12 FY2025 appropriations bills thus avoiding a shutdown. It’s election season, so a continuing resolution to fund the government into 2025 will pass at the last minute so politicians can play partisan brinksmanship and enjoy media coverage through September. In the same period, the Fed will announce its much anticipated interest rate cut decision on the heals of growing fear of an economic slowdown. It’s a serious time for healthcare!