In Health Care, the Market Mindset is Hard to Break

This article was originally published by Eric Haas of the Rockridge Institute on November 5, 2007.

A recent article in the San Francisco Chronicle, entitled A Profession is Born to Help People Navigate the Health Care Maze helps demonstrate that it can be hard to change our ways of thinking, even when they aren’t working very well.

Cognitive science has demonstrated the power of mental frames. They are physically part of our brains, created through the configurations of our neural circuitry. Once established, the neural circuits do not change quickly. So, we think, mostly unconsciously, in certain ways and it’s hard to break our habits of mind. As a result, we often solve new problems using versions of the same old solutions, sometimes piling one on top of the other. It’s hard to teach an old dog’s brain new ways of thinking.

This is certainly true in health care. In the U.S., we’ve been so accustomed to thinking about markets as the solution to everything that we think of health care as health insurance delivered by companies competing against each other in the marketplace. But care and insurance are not the same—ask the millions of under-insured people whose policies do not cover the medical treatments they need. As a result, they are suffering unnecessarily and dying prematurely. (My Rockridge Institute colleagues and I examined this in The Logic of the Health Care Debate.)

Further, we know that the insurance market itself is the problem: insurance companies operate to maximize profit and must compete against other health insurance companies to do so. The intense competition to make profit causes people to get poor treatment for two reasons. First, competition encourages insurance companies to avoid the people who need care the most. This is because the competitive insurance marketplace doesn’t spread the medical risks and costs evenly among the companies. So health insurance companies avoid people needing medical care by refusing to cover them or by charging such high premiums that policies are unaffordable to millions of Americans. (I discuss this further in SCHIP and the Rigged Health Insurance Game.)

Second, even people with insurance often get poor care because health insurance companies make more profit by authorizing less care. Care is an expense that when minimized, increases profits. So, insurance companies have a strong incentive to deny care to policyholders.

Clearly, the insurance marketplace is the wrong way to try to keep Americans healthy.

But this doesn’t mean that we don’t keep hearing about new market solutions to solve the current market problems. Case in point, is this recent article in the San Francisco Chronicle. The article is about a new type of health care professional—the Health Care Advocate (HCA). An HCA “specializes in helping patient and their families cut through the health care bureaucracy to find the help they need.” The article goes on to describe HCAs as a new and helpful innovation—”people are overwhelmed by health care and are seeking people to help them out with it.” But it is likely an expensive one. Most insurance policies do not pay for HCA services.

From the point of view of framing, this is an interesting—and quite expected—way of thinking. Most Americans are accustomed to thinking of the health insurance marketplace as a “system” for providing care; however, health insurance companies are first and foremost profit-maximizing corporations. They protect their profits through an impenetrable collection of regulations and gatekeepers that sick people and their families cannot navigate when then need specialized and extensive care. This poor treatment occurs despite Americans spending more money per person on health care than any other industrialized nation in the world. Yet, the solution embraced in the San Francisco Chronicle article is for patients to pay additional money on top of their insurance premiums to an HCA to help them use the system the insurance companies have created. When you are thinking with a market mindset, then another market solution may be all you can muster. Market solutions simply make sense, even when experience and facts demonstrate their ineffectiveness.

The power of mental frames might be best summed up by a quote near the end of the article from Margalit Mathan, a mother using an HCA to help with her daughter’s juvenile rheumatoid arthiritis.

“It’s unfortunate we need it, but in the system we all live in right now, if you’re dealing with something really complicated, I can’t say enough about how helpful it is,” Mathan said.

Rather than finding HCAs as another example of the failures of our current market-based health insurance system, the Mathan and the Chronicle article present them as a positive solution to a problem that seems to have arisen naturally, without cause. Mathan and the Chronicle appear to have a hard time thinking outside the market frame for health care. In this, they are similar to nearly every Democratic and Republican presidential candidate.

It is for examples like this that we at the Rockridge Institute contend that changing the way we think—our mental frames—must go hand in hand with changes in policy. Especially in health care.


Cognitive Policy Works specializes in providing organizations and individuals with frame analysis, policy briefs, strategic advising, and training.

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