The Unbearable Lightness of Medicare for All

I love the idea of universal health care.

I grew up in Canada, and have lived in the US for the last 25 years. When I first moved to Florida for grad school, I was impressed by the timeliness and modernity of US doctors and other facilities, and even worked for a while at an Electronic Health Record startup (EHRs were just around the corner…in 1995).

For a long time, I had a smug reaction to conversations with my family and friends back home about healthcare. They’d bring up their complaints with OHIP (the Ontario Health Insurance Plan, our health administration — bet you didn’t know there is no national health system in Canada). Most of these were centered on long waits to see doctors or get procedures, and I’d respond with a quip about how I got an MRI for back pain with only 72 hours notice.

I was very much in the “haves” category in the US health system, with pretty good insurance for the majority of my time here. But as the years passed, and I had more terrible interactions with insurance companies, I came to realize the fundamental truth that underpins US health care: insurance companies don’t make money by paying claims. In a bizarre sense, the organization most closely entrusted with ensuring my health and longevity was — in fact — trying to undermine that goal.

Like the time I had an asthma attack at 2am. I went to the nearest hospital, fearing a serious emergency. By the time I was seen, my symptoms had calmed down, and doctors sent me home with some scripts. My insurance denied the claim, because the doctors did not write it up as an emergency, and I had to threaten legal action to get them to back down. It was quite a wake up call, and it made me realize how good — if creaky — the Canadian system could actually be.

So each time healthcare became a major political issue in the US, I got very excited. I advocated during Hillary’s push, Obama’s push and now the Democrats push for a universal system that would bring costs down, ensure everyone was covered and deliver better quality care for less. I believe in the moral and ethical rationale for nationalized health care, now more than ever.

Being disappointed in the US political system is nothing new, and on this topic, I’ve experienced more emotional peaks and valleys than a Sondheim musical. I feel like the song of single payer in the US just keeps playing on repeat:

“National Health Care”
“Government between Doctor and Patient”
“National Health Care”
“Death Panels”
“National Health Care”
“Give up your insurance”

At the beginning, I thought the objections — mostly voiced by Republicans — were absurd, and that any thinking person could see through them. Over time, I’ve come to realize two important things:

Fixing #1 will take a generation or two of concerted effort — and I’m saddened that no one is advocating for essential educational reform. Fixing #2 however, seems like a much more pressing issue — and one that the current Medicare for All discourse seems to simply paper over.

This is now borne out in research from The Commonwealth Fund indicating that people with employer-sponsored insurance strongly disfavor having to give their plans up. This objection is core to the reason why universal health care hasn’t come to pass in the US, and probably isn’t going to happen this time around either.

In the main, middle class voters need to be persuaded to give up their insurance “autonomy” (however vague and illusory it may be). And persuasion requires concerted, clear and emotionally-appealing allegories and messages that make the receiver feel better about themselves for having made a good choice. Giving up autonomy is very hard for people, just consider the emotional toll of going to prison or becoming bedridden. We must employ People Management 101: make ’em think something was their own idea in order to get them to really embrace it. That takes creative and thoughtful persuasion.

Unfortunately for Bernie’s most ardent supporters, you can’t moralize, criticize and belittle your way into changing people’s opinions. Most adults reject this persuasive approach even if warranted because it feels like an attack on their ethics and ego (just try calling someone a racist). It seems that many of the folks advocating for M4A seem not to have gotten this message.

In 2010 Congress and President Obama signed and enacted the Affordable Care Act. Though it was a watered-down version of the national health care plan initially proposed, it was nonetheless very poorly received. Now, the law has a much better public image and you can see the transition in opinion in this research from KFF. The ACA started out doing ok, and quickly lost ground to negative opinion. It took years for the “reality” of its improvements to catch up. That is — even though Obamacare created major benefits for people, their appreciation for it was uncorrelated to its value.

The missing piece: effective, persuasive marketing of the concept. I remember thinking at the time that if a charismatic autocrat — let’s say Chavez, Putin or Xi — had implemented a major national program to benefit the poor, you would find their face beaming down at you from every street corner and media platform. The message: “Thanks to Obama, you now have health care.” If you’ve traveled anywhere in the classic Socialist world, you’ve seen the kind of propaganda I’m talking about.

Here, we did no such thing, much to my bafflement. The ACA had minimal marketing, hasty implementation and a message that was contradictory. Somehow, the US government forgot how to do effective, persuasive, propaganda. During WWII it was great at it — creating a set of iconic posters and catch phrases we still use today — to get people to volunteer, buy bonds, report suspicions and keep secrets.

Then, at some point in the late 20th century, as the discipline of marketing took off, the government forgot how to do it. And the political discourse that followed seemed to assume that people could make good decisions based on facts, even though evidence says facts are not very persuasive.

This had led many well-meaning progressive advocates into a moral sandtrap from which they cannot emerge:

“I’m not going to sit here and explain to you…”
“Maybe you’re the problem…”
“If you don’t believe in this, then you are an ____”

etc etc.

You wouldn’t like hearing these things from a spouse/partner, and you definitely don’t like hearing them from someone trying to convince you of something. And while indignance and belittlement may be easy (or even morally superior), advocating for change in this way is 100% not going to work.

Behavioral engineering and persuasive messaging are my profession, and I’m going to repeat that again, so everyone in the back can hear it:

Moralizing to, bullying and belittling people whose support you need is not an effective strategy for changing hearts and minds. Persuasion is.

And if you think persuasion is beneath you, or morally questionable, you need to take a step back and ask yourself why you’re so sure that your perspective is right, and that others should simply forgo their autonomy and decision-making. If you believe that people have basic dignity and rights, including self-determination, then your lack of willingness to meet them in conversation is the act of a defiant, petulant and — frankly — delusional thinker. When your strategy fails (and it will), the only logical next step is force, and that is always met with even more resistance.

This time around, if we really want Medicare for All to work, we need to spend less time talking about the structure, facts, economics and morality, and start talking to the voters we must persuade. We need a cogent message that can reach them about why M4A is the right choice, and why whatever trade offs they may have to make are worth it to them. That means fitting our conversation into their frame of reference so that we can meet them in the middle.

Pete’s Medicare for All (who want it) strategy is specifically designed to be persuasive and avoid this dialectical trap. Underpinning his approach is a concerted effort to make the “public option” the best choice, but to let people decide how and when they want to participate in it. This concept should be pleasing to everyone who believes in basic human rights. It’s also smart because companies will begin dropping healthcare as a benefit once it’s publicly available, further pushing people to the public option.

At the same time, even Pete’s approach or “true” Medicare for All needs marketing and persuasion. We need to explain how and why this is a superior option not just to help-thy-neighbor, but also to help thyself. In my experience, one of the best ways to do this would be to simulate for people what would happen in various future scenarios.

Humans are bad at predicting the future, so simulation and scenario planning gamification is essential to this task. Imagine a “future life” game in which you enter some details about your insurance plan and then can see what happens if you develop cancer, have a child with a congenital defect, or you need round the clock care for your spouse.

Even someone with decent income and good insurance can be devastated if a family member develops a serious illness. We need to show people what happens when you reach your maximum benefit, etc. — not just tell them. Helping someone understand that and make good choices today is hard, but will produce much better outcomes for all of us.

Or consider a mock insurance marketplace where you can sign up for virtual insurance plans, including a national option. Such a simulator would allow people to compare and contrast the plans’ table of benefits and costs using the now-familiar ACA-mandated standard form. Those with more experience buying plans (who also happens to be the person in the voting booth who will be making the crucial call) could find this useful for understanding the essential trade offs.

Another concept: you could use some aspirational gamification. Ask people to visualize what they’d like to be doing in 5, 10 or 20 years — including family, career, health, etc. Based on those inputs, show them how the path to achieving their goals gets shorter with M4A.

A final idea would be to build a game that lets people take control of a hospital and respond in real time to mounting demand for services from various populations. As you fight to allocate resources and collect from patients, you run into the obvious economic trap of the current system. This might help people understand the underlying economic conflicts.

Every one of those approaches above has been done in various ways, by various industries and companies, and using various technologies to persuade people. For example, AXA built a very compelling “death simulator” that helped stimulate demand for life insurance. Or the popular indie game “Papers Please” which had you playing a border guard in a fictional country, having to make moral choices about immigration in real time.

These are only a few ideas that could shift the conversation. And I believe that everything should still be on the table. But if we want Medicare for All, we need to address this looming crisis head-on with persuasion and good ideas and not just empty moralizing.

And that’s what makes the current debate so dispiriting. Advocates for M4A are failing to grok that the existential threats to their idea are not other Democratic proposals, but rather customer (and yes, they are customers of your political agenda) inertia and resistance to change. In a sense, they fail to understand that they’re selling a product, and to do the essential marketing necessary to make it work.

So Medicare for All, as currently proposed, is like a half-finished business plan from a second tier startup accelerator. The slides look good but without a customer acquisition strategy. As any entrepreneur or investor will tell you, this is a huge red flag that suggests advocates haven’t done their homework.

For all these reasons, I’m deeply concerned that Medicare for All as envisioned by both Sanders and Warren is doomed unless there is a more cogent approach to finding product-market fit. Yes, polls say that most people want M4A, and that people are unhappy with their current insurance. But the devil is in getting them to make an active choice to give up what they have now and switch. That is much easier said than done.

We are on the cusp of tremendous potential to right this injustice. But this shallow, childish and undisciplined approach dooms it to failure.

Author and Public Speaker on Gamification, The 4th Industrial Revolution, the Future of Work and Failure. More about me:

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