How Osama Bin Laden Ruined Health Care

For something that affects whether you live or die, go bankrupt or remain solvent, and that accounts for nearly one-seventh of the nation's economy, health care has been the Washington, D.C., version of Ishtar: high expectations, but a bomb. In a Kaiser poll last month, only 44 percent of those asked said reforming health care should be a top priority. For that apathy, says Harvard psychologist Daniel Gilbert, you can blame the fact that your rising insurance premiums, your increasing co-pays and deductibles, the soaring number of uninsured Americans (projected to reach 52 million by next year), and every other flaw in the current system is...not Osama bin Laden's fault.

No, really. A threat needs to have certain properties "to ring our alarm bells," says Gilbert, author of the 2006 bestseller Stumbling on Happiness. One is that it needs to come with a human face—preferably an evil-looking one; extra points for beard and mustache—since evolution shaped the brain to pay attention to and leap into action at threats posed by humans. (Evolution is too slow to have shaped us to become outraged by, say, lower reimbursement for branded drugs than generics.) But the mess that is the current health-care system in the United States "hasn't been visited upon us by an evil monster," says Gilbert. "It's the fault of a faceless 'system,' and that's not something we're wired to jump up and down about." If a bin Laden or any other specific villain were behind the troubles with the current system, you can bet that the percent of people calling reform a top priority would soar. (Indeed, when an individual doctor denies some poor soul ER care or when a hospital dumps a poor patient on the street, public outrage boils over, because the victim and villain come with a face and a name.)

Nor do the problems with the health-care system stir moral outrage—or, more precisely, not the truly powerful variety of moral outrage. Sure, people might gin up sympathy for the uninsured, or for someone so underinsured that he falls victim to medical bankruptcy But that's nothing compared to the disgust triggered by something having to do with food or sex. Again, a reflexive aversion to, say, maggot-laced meat or incest is part of our evolutionary inheritance; moral disgust at insurance companies that sell policies with coverage holes big enough to drive a truck through...not even close. Feeling outrage at the latter requires a major assist from the part of the mind that does higher-order thinking, which can't compare to emotion when it comes to making people grab a pitchfork and storm the castle.

For that, an issue must also present an imminent threat rather than one that's barely visible over the time horizon, says Gilbert. The health-care system has been slowly deteriorating over the last couple of decades—more uninsured, unaffordable premiums, skyrocketing costs, and insane overtreatment but the key word there is "slowly." "We haven't seen a radical, sudden change in the last few years," says Gilbert. "If we'd all been used to high-quality, concierge-style care and then found ourselves with this, we'd be up in arms. But we've had 'this' for a long time. You can subject people to almost any outrage, and if you do it in slow enough increments they hardly notice, let alone get upset."

In short, health care "lacks all the features that you need to stir people out of their apathy," he says. (In a 2006 op-ed in the Los Angeles Times Gilbert applied a similar analysis to why climate change doesn't outrage more people, arguing that if it "had been visited on us by a brutal dictator or an evil empire, the war on warming would be this nation's top priority...[G]lobal warming is bad, but it doesn't make us feel nauseated or angry or disgraced, and thus we don't feel compelled to rail against it.") And it has the additional quality of being hard for most people to understand (health co-ops vs. government insurance, anyone?).

The additional bad news for proponents of health-care reform is that the other side has easier and more-effective fear-mongering at its disposal, as they showed brilliantly with the "Harry and Louise" ads that the insurance industry funded the last time around, when the Clinton administration tried to overhaul health care. Socialized medicine! Government doctors! Rationing! The obvious ways to rile up the public on behalf of health-care reform—blaming the current mess on someone and inciting moral disgust—aren't likely to work, says Gilbert. "You can say that insurance companies are plotting to give you bad medical care and take more of your money, but faceless bureaucrats don't make an effective enemy," he says. "The best bet may be to frame it as, 'wouldn't you like to save money on health care without sacrificing quality?'" Gilbert admits that he's stumped about the details of such an approach, but, he says, "I have the feeling Lee Atwater could have figured it out."

© 2009