Peter Ubel

Okay, as fine as is her midriff, most of you probably don’t list Megan Fox’s belly button as her first, um, attribute worth pondering. But bear with me–her belly button IS key to understanding why the Massachusetts senate seat just went to a Republican, and why Democratic efforts to reform our healthcare system are now all but history.

In the old days, you see, if a piece of legislation garnered 59 votes in the Senate, it was rightly perceived as the product of a national consensus. Landslide kind of stuff. The will of the people.

However, in the old days, the two major parties were much more diverse. The Democratic Party included Southern conservatives, while the Republican Party, the party of Lincoln, included Yankees who, today, would at most be centrist Democrats.

Then … along came Megan Fox’s belly button?

No, be patient gentle readers. Fox will enter our story soon. But first came another person, someone whose belly button was, to my knowledge, not a focus of anyone’s lascivious mind. Along came Lyndon Johnson, a Southern conservative at heart, but a power-seeker to the core. And to consolidate his power, Johnson had to find a way to convince Southern conservative Democrats to support civil rights legislation. In doing so–in cajoling conservative Democrats to vote against their long term opposition to such legislation–Johnson effectively began the slow re-sorting of the two parties. Ronald Reagan accelerated this re-sorting. And eventually the Republican party pulled Southern conservatives away from the Democrats, while the Democratic party became, itself, more uniformly liberal.

And that is almost when Megan Fox’s well-toned abs began to grab the attention of my peri-adolescent son. But she’s still not ready to enter the story.

First, one more thing happened that I want to tell you about. Barack Obama became President of the United States, and the Republican Party–now almost uniformly conservative–pulled together in opposition to any and all Democratic legislation, cheered on the sidelines by conservative websites and cable news organizations. The result is that we now have a politics of us versus them, of Republican/Conservatives versus Democrats/Liberals.

In the old days, if you pulled together all the conservatives in Congress to craft a piece of legislation, you would have to grab a mix of Republicans and Democrats. The same would have gone for liberal legislation–you would need a mixture of Midwestern Democrats and Northeastern Republicans.

But now, with the parties so unified ideologically, politics is like belly buttons–innies are good, and outies are bad. For all of Megan Fox’s beauty, if she had a serious outie, her agent would be working overtime to hide this part of her body from photographers. We relate to people the way we judge belly buttons. It really matters to us whether we consider the other person to be an innie or an outie–what social scientists call “in groups” and “out groups.”

If you place orange dots on half the kids in a fourth grade classroom, and green dots on the other half, pretty soon the orange kids will start excluding the green ones from their play groups. In no time, in fact, friends will be torn apart by this artificial in group/out group manipulation. You literally will have fights on your hands, simply because the green kids will perceive the orange kids as some kind of competing group.

The American public is not famous for its knowledge of politics. That’s why when most people judge upcoming legislation, it matters less to them what the legislation proposes as who proposes it. If George Bush had proposed health care reform that resembles the current Democratic plan, it would have been perceived as some kind of ultra-conservative legislation by Democrats. “There he goes, helping out greedy insurance companies again.” But instead, the same legislation proposed by the Democrats is viewed, by Republicans, as Socialism. Innie and outie–so much of politics depends on this single perception.

In the old days, a liberal Democrat might propose a piece of social legislation to one of his conservative Democratic colleagues, and the conservative would at least consider the merits of such legislation as a favor to someone who is in his own political party. Even if this conservative ultimately decided not to support the legislation, he would be unlikely to filibuster (as long as it didn’t have anything to do with Civil Rights) because he wouldn’t want to stand in the way of his own colleague’s legislation.

Today, legislation stalls not just because it lacks 60 votes in the Senate but, more importantly, because those votes rarely cross party lines. It is easy to filibuster someone who belongs to an out group–who has the wrong colored dot on his head.

The unification of our two parties into tighter ideologic entities is thwarting our ability as a nation to tackle the challenges we face. We need to cut the umbilical cord that tethers ideology to partisan politics.

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It is pothole season in Michigan, with roads crumbling under the pressure of winter cold. Then again, with the condition of our state’s dismal economy, pothole season is becoming a year-round phenomenon here in the Great Lake State. Michigan’s government can no longer afford to fix roads like it used to, and the same goes for bridges, water mains and other infrastructure. And don’t even get me going on budget cuts to our public education system.

While Michigan’s auto-based economy is the main cause of our fiscal distress, physician that I am, I cannot help but see MRIs lurking at the bottom of the sports-car-sized pot holes that litter the roads on my daily commute. An MRI costs a few thousand dollars a pop, you see, and we doctors order such tests almost unthinkingly. Back bothering you? Shoulder pain lasting more than a week? And that blip on your liver enzymes? We need to make sure nothing terrible is going on. Time for an MRI!

Our willy-nilly use of MRIs occurs in part because we doctors don’t pay for these tests. In fact some of us (but not me!) actually make money by ordering these tests.

The same goes for medical procedures. A primary care physician like me makes a token amount of money during a routine (and frequently time consuming) annual checkup. But if we can bring that same patient back for a skin biopsy, that ten-minute visit smells to me like a college tuition payment!

So we physicians order tests and procedures, and other folks pay — sometimes insurance companies, sometimes patients themselves, and increasingly often, the government through Medicare or Medicaid. Eventually, of course, we all pay for these tests and procedures. Our crazy health care system is basically a huge transfer of income from the general public to people in the health care industry.

States like Michigan are facing enormous budget pressures in the face of the recession. But even before this recession hit, many states were starting to buckle under the strain of Medicaid inflation, leaving huge SUV-sized holes in their annual budgets.

We need healthcare reform because we need to control health care costs, or we will end up with an infrastructure that would embarrass a third world dictator.

And the Democratic party needs to tell us more about how its reform efforts, should they succeed in the face of the Massachusetts senate debacle, will control costs.

And the Republicans need to stop whining about healthcare rationing, if they actually care about the future of this country.

We are facing a serious challenge. If politicians don’t meet this challenge, we will all have lots more to worry about than potholes.

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It’s easy to criticize the Obama administration, isn’t it?

Look at the unemployment rate. Or, have you heard about the tax hikes that some say we will need to pay to cover health care reform? Oh yeah, and the administration did a great job with Umar Farouk Abdulmutallab didn’t it? His dad told us he was going rogue, and then when he buys a ticket with cash and doesn’t check in any luggage, we are still caught off guard. Time to say this in unison now, folks, with your most sarcastic tone of voice: “Great work President Obama!”

Is it too soon for such sarcasm?

Folks, before we start blaming the government for all these terrible insufficiencies, we need to remember that hindsight is not even close to 20/20, and that we cannot accurately judge what our government is doing (or not doing) for us until we pay attention to what I call “the Politics of Invisibility.”

You see, there is some invisible stuff that must be paid attention.

Let’s start with the country’s unemployment rate. I live in Michigan, and I’m one degree of separation away from a hell of a lot of unemployment. I am not at all happy with the state of our nation’s economy. And I would have liked to have seen us make more progress over the past year in addressing our economic woes. But before we criticize Obama’s economic stimulus plan–on the grounds that it has not ended unemployment as we know it–take a moment to ponder the invisible: ask yourself what the employment rate would have been if Obama hadn’t pushed his stimulus plan through a reluctant Congress. Don’t know the answer? Welcome to the Politics of Invisibility.

How about the taxes some say we will pay to fund healthcare reform. At first glance, it seems that there’s nothing invisible there. But take a closer look. Do you have any idea how much of your current income has been funneled into the healthcare industry? Consider that “free” healthcare benefit your employer gives you. That benefit comes out of your income. Many middle-salary wages, in fact, have stagnated in recent decades in the U.S., largely because employers have been taking what would be salary increases and pushing them over to cover the spiraling cost of healthcare benefits. And that tax break we get for our employer-based health insurance? That’s not free either. That contributes to government deficits, and ultimately forces the government to raise taxes. Nothing is free. But because of the Politics of Invisibility, we find ourselves whining about healthcare taxes at the same time we overlook the way healthcare insurance has already shrunk the size of our paychecks.

Finally, let’s revisit the TSA’s performance in the recent underwear bomber fiasco. I admit to being shocked, with the rest of the nation, at how many clues the Feds overlooked in allowing this man to board a plane with a bomb strapped to his crotch. But a moment’s reflection on the Politics of Invisibility forces us to take a more cautious view of the TSA. Consider one of the smoking guns that critics of TSA have been discussing vehemently in the blogosphere–that this terrorist stepped onto the plane WITHOUT CHECKING ANY LUGGAGE.

Ummmm, I think he means he placed his luggage into the overhead bin. You know, like half of his fellow passengers!

Now I understand that most of those other passengers’ fathers hadn’t recently told the CIA that their son was becoming radicalized. And that most of them hadn’t paid for their tickets in cash. But I don’t know, as an ordinary citizen, just how many people would have fit the underwear bomber’s profile. How many young men have come under the influence of passionately radical Imams and then boarded planes after paying for tickets with cash? I don’t know that number. I expect the number is in the tens of thousands, if not more. (And is paying in cash really that significant? If we started scrutinizing cash payments, wouldn’t terrorists simply start using credit cards? For that matter, wouldn’t they start checking luggage, if that turned out to be a security red flag?)

What’s invisible here is the denominator–how many people, if they try to blow up a plane tomorrow, would have a string of “clues” that would have made the bombing attempt look inevitable? It may very well be that very few people were as risky-looking as the Underwear Bomber. But frankly, that information is invisible to me, as it is to most of the general public.

Before we get all high-and-mighty about the terrible job that security experts are doing, we need to ponder the Politics of Invisibility, and remember that it’s easy to criticize what we see, even as we ignore what we can’t.

Peter Ubel is George Dock Collegiate Professor of Medicine at the University of Michigan, and author of Free Market Madness: Why Human Nature is at Odds with Economics–and Why it Matters (Harvard Business Press, 2009). Visit http://www.peterubel.com/ for more blogs and research updates.

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If I told you that neighborhoods cause people to develop diabetes, would you believe me? And would that make you more or less willing to see your tax dollars spent researching ways to treat and prevent diabetes?

That is essentially the question my colleagues and I posed to a wide swath of Americans, and a question, we discovered, that polarizes people along political party lines.

What do I mean when I say that neighborhoods can cause diabetes? Well, social scientists have linked neighborhoods to disease. People living, for example, in neighborhoods with poor sidewalk access end up walking less than people in other kinds of neighborhoods, thereby gaining weight and developing diabetes. By a similar token, if a neighborhood is too dangerous for people to exercise outdoors, people become more sedentary and, voila, diabetes predictably ensues in a subset of the population. What’s more, some neighborhoods have a terrible supply of grocery stores — people living in such neighborhoods can easily avail themselves of fast food restaurants, but can’t necessarily find fresh produce.

Often when people learn that forces beyond individual control contribute to illness, they become more supportive of public funding to combat those illnesses. In fact, in our study we provided a random subset of research participants with a news story explaining that diabetes is caused by genetics (this is true, by the way — genes do contribute to diabetes.) People reading this news story — whether Republican or Democrat — became more supportive of spending public funds to treat and prevent diabetes.

Then we gave another subset of participants a different news story. This one explained that diabetes is caused by neighborhoods. Once again, hearing about the forces that contribute to diabetes made Democrats more interested in spending money on diabetes research. But the Republicans who read this news story weren’t persuaded; in fact, they became less willing to use tax money to tackle the diabetes epidemic.

It is easy to believe that our country is politically polarized simply because people have gravitated toward partisan media outlets. Watch Fox news and you will hear about Tea Party demonstrations; watch MSNBC and you will hear about Gay Rights demonstrations. No surprise that when people receive imbalanced information, they end up with polarized attitudes.

However, our study shows that our nation’s political divisions run much deeper than the Glenn Beck/Keith Olbermann divide. In our study, Republicans and Democrats came to starkly different opinions from each other even after receiving identical information about the cause of diabetes. Hearing about neighborhood effects on diabetes brought out compassion among Democrats, but not so much among Republicans. As some of my Republican friends tell me when I talk to them about neighborhoods and illness: “The neighborhood doesn’t force people to eat at McDonalds. Even if a neighborhood is dangerous, people can do Pilates in their living rooms if they’re motivated.”

True enough. Human behavior is ultimately the main cause of diabetes. But no person’s behavior is completely under their own control. Social forces can influence people’s behavior — the kinds of social forces that differ across neighborhoods, for example. Sadly, when people think about these other forces, some are more convinced than others, and these divisions run across predictable party lines.

To reduce partisanship in this country, we need to educate more people about the complexity of human nature. I wonder if the 24 hour news channels will find the time to do that!

Our study, led by Sarah Gollust, was published in the October issue of the American Journal of Public Health.Free Market Madness. Read more of my blogs here.

My most recent book is

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In an effort to be the first president since Lyndon Johnson to succeed in reforming our nation’s health care system, President Obama is exhibiting honorable flexibility. Taxing health care benefits for employees? He was against it when running for office, but he is considering it now that the federal budget deficit is growing so rapidly. A new public insurance plan? He promised this spring that it would be a central part of his health care reform efforts, but now he is willing to put it aside in pursuit of more important goals.

And what are those more important goals? First and foremost, the President wants to expand people’s access to health insurance, so that their medical care will no longer be threatened by job loss or by what an insurance company determines to be a “pre-existing condition;” and second, he is committed to controlling health care costs, aware that our future fiscal solvency depends on slowing the growth of Medicare and Medicaid.

The time may come for Obama to shed one of these two laudable goals. Indeed, if blue dog democrats begin turning away from health care reform because of budget concerns, Obama will need to give up his immediate plans to expand access to health insurance, and focus his efforts, instead, on showing the American people that he knows how to control health care costs.

I recognize the moral horror that my proposal will create among those people who, like me, are outraged that a wealthy country like ours allows 50 million people to go without health care insurance. Obama is correct, in fact, to be exhorting Americans to recognize our moral duty to offer basic health care coverage to all our citizens.

But with ballooning budget deficits and an economy still on the brink of disaster, it may not be politically palatable to expand health insurance coverage right now. Most conservatives, and even many moderates, are understandably worried that the government will do the easy job of spending money it doesn’t have, while ignoring the more difficult job of making our health care system more efficient. After all, Obama has not really laid out a clear plan for how he will control health care costs. Instead, he is simply asking people to trust him: somehow, with a teaspoon of electronic medical records and a few milligrams of “comparative effectiveness research,” he will cure the health system’s inefficiencies and make our financial problems go away.

I suspect that Obama already realizes that he cannot achieve both of his goals — expanding access and controlling costs — in the initial stages of his reform efforts. Instead, his administration appears to be taking a Massachusetts-style approach to health care reform: expand coverage first and then, after costs spiral further out of control, take on the difficult job of ratcheting down health care costs. In this approach, expanded coverage is the horse that pulls health care reform along what will no doubt be a long and winding road.

This access first approach is morally laudable and may even be politically wise. But politics moves quickly — who, after all, would have predicted three months ago that “death panels” would play such a large role in public discourse about health care reform?

If fiscal concerns threaten to impede Obama’s health plan, he will need to change direction. At that point, the best way to expand health care coverage to all Americans will be for Obama to focus, over the next few years, on proving to Americans that he can control health care costs — indeed, that he has a legitimate plan for controlling government expenditures more broadly. With this proof established, Obama will then be able to propose reforms that will expand health insurance coverage, and the American public will have confidence that these reforms would not break the bank.

With so many Americans worried about rising taxes and runaway budget deficits, Obama should consider putting the cart of cost control in front of the proverbial horse. If Obama can prove to us that he can rein in Medicare costs, the American public will gladly follow him further down the path of health care reform.

Peter A. Ubel M.D. is author of Free Market Madness: Why Human Nature Is at Odds with Economics — and Why It Matters (Harvard Business Press, 2009), and George Dock Collegiate Professor of Medicine at the University of Michigan.

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Did you know that Adolf Hitler had three testicles?

You didn’t? Well, you are right. That is just an urban legend — one that I have just created.

In fact, if anyone tells you that Hitler had three testicles, they are either misinformed or they are lying.

Why am I mentioning Hitler’s three testicles to you right now? Because by mentioning the myth of his three testicles, and debunking that same myth, I am actually increasing the odds that some time in the future you will mistakenly believe that Hitler really did have excess, um, baggage.

Behavioral scientists have discovered that familiarity breeds belief. In research studies, they have exposed people to series of true and false messages, telling people at the same time which of those messages were true or false. Later, they exposed people to these same messages, and asked them whether they thought the messages were true or false. They found that previous exposure to these messages increased the number of people who believed these messages were true, even the messages that had been identified as false.

How does this happen? People remember hearing the message (”Hmmm, three testicles, that sounds familiar”), but forget learning that the message was false.

Therein lies the brilliance of Sarah Palin’s death panels. Having heard this rumor countless times now, casual observers of politics (a.k.a. the majority of the American public) will come to believe that the rumor is true.

Lying, unfortunately, can be smart politics. And countering those lies by pointing out their falseness — that won’t be enough, if we believe what behavioral scientists have learned.

Proponents of health care reform must not only debunk these myths, they must also create powerful images to counter those myths — images of how health care reform would improve people’s lives. Images that can compete, if not with extra testicles, then at least with Sarah Palin’s face book page.

To learn more about my new book, Free Market Madness, check out my website: http://www.peterubel.com/.

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Republicans criticizing health care reform efforts are beginning to sound as principled as Groucho Marx, who once quipped: “Those are my principles, and if you don’t like them, . . . well I have others.” On the one hand Republicans complain that health care reform will cost too much money. On the other hand, they complain that Obama will ration care, killing your grandmother if he has to, to save money.

These two arguments are as consistent as what British people call pudding, about as coherent as a Sarah Palin resignation speech. And yet, it is the Democrats who, according to common wisdom, are divided over health care reform?

In fact, the battle over health care reform nicely summarizes the state of the two parties. The Democrats are deeply engaged in this important issue, struggling to find a way to pay for the health care our country needs, stumbling along the way due to the incredible complexity of our health care system, but nevertheless trying to move forward.

Meanwhile, the Republicans (except for a small number of moderates) refuse to acknowledge the importance and seriousness of this issue. All they care about is to oppose whatever plan the Democrats come up with. Hence, they throw out inconsistent criticisms without regard for their inconsistency.

The sad thing is, some Republicans really are concerned about the cost of health care reform. And others really are worried about how government will try to set limits on medical care. But to simultaneously complain about the financial cost of health care reform and about the cost savings that will follow from health care reform? This strategy merely reveals the current Republican Party as being uninterested in solving important social problems.

It is easy for a Party to be unified if its members are allowed to make incompatible claims about crucial policy issues, without acknowledging their own internal inconsistencies. If Republicans were honestly trying to help shape legislation, they would be every bit as divided as Democrats. Their current unity is merely a sign of their political self-marginalization.

We should all be concerned about the current state of the Republican Party. Health care legislation will be better if Republicans try to shape it, rather than merely trying to sabotage it.

We should all be thankful that the Democrats care enough about health care reform to have honest disagreements with each other. A Party divided is the sign of a Party deeply engaged in the issues. We can only hope that Democrats will come close enough together in the near future to begin fixing our badly broken health care system.

To read more of my blogs, and to learn more about my new book, Free Market Madness, check out my personal website.

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Any sensible plan to reform the U.S. health care system must reform the way we pay physicians. Currently, we reward doctors for doing more “stuff” for their patients — for performing tests and procedures whether or not these interventions are necessary. Because of this strange reimbursement system, many primary care physicians receive more money performing a five-minute skin biopsy than they do conducting an hour-long history and physical.

Yet as important as it is to reform how we pay physicians, it is even more important for us to have an honest national discussion about how much we pay physicians. In the U.S., the median anesthesiologist makes more than $350,000 per year. That doesn’t mean these people feel overpaid, however, for on the other end of the operating table their neurosurgeon colleagues make more than $600,000 per year, while down the street in the outpatient clinic, their dermatology colleagues pull in close to $400,000 per year. According to data collected by the American Medical Group Association, over two dozen medical specialties earn a median income of more than $300,000 per year.

In part, these physicians make lots of money because they perform lots of procedures. That means that if we reform the way we pay doctors for procedures, we might chip away at these astronomical incomes. But if we plan to reform our payment system, to discourage doctors from performing questionable procedures, we still need to decide how much money we want doctors to make. Obama has spoken fondly of the Mayo model of health care, in which physicians receive salaries, thereby reducing their incentive to perform unnecessary procedures. But Obama hasn’t said what physicians’ salaries ought to be, should the government make efforts to encourage a salaried medical system.

Health care reform ought to be forcing us to take a hard look at just how wealthy U.S. physicians have become in the last few decades, far wealthier in fact in their colleagues in other developed countries. Yet this topic of doctors’ incomes has been largely ignored in the public debate that has surrounded health care reform.

Doctors need to take the lead in making this issue public, and developing a solution to the problem. Politicians certainly aren’t going to tackle the issue of physician salaries. Republicans have committed themselves, sadly, to fighting whatever health care plan the Democrats put together, in hopes of weakening the Obama administration. And the Democrats are too afraid of medical organizations, like the AMA, to honestly address the issue of physician incomes.

Leading medical organizations should work with Congress to broker a deal. Perhaps a 10% cut in physician income (with smaller cuts, perhaps, for specialties that bring in less than $300,000 per year), in exchange for rigorous reform of medical malpractice law.

Rising health care costs threaten U.S. industry, which cannot compete with foreign companies that face lower costs; rising costs also threaten federal and state budgets, which are buckling under the strain of Medicare and Medicaid expenditures. Doctors need to do their part to lower health-care costs, by giving back some of their very generous income. And politicians need to work more closely with doctors, to make such a loss of income worth their while.

Peter Ubel is a primary care physician at the University of Michigan, who does not make even close to $300,000 per year, but who’d gladly take a pay cut to help move this country toward a more sensible health care system. He is also author of Free Market Madness: Why Economics is at Odds with Human Nature — and Why it Matters. Read more about this overpaid doctor at http://www.peterubel.com/ .

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American presidents have been trying to reform our health care system since at least the Nixon era, but with only limited success. Past reform efforts have failed for many reasons. For starters, the U.S. health care system is complex, with the medical industry making up almost 1/6 of our economy. But perhaps the biggest obstacle to reform is a psychological one: thoughts of health-care reform too often trigger images of putting for bogey instead of putting for par.

I am referring to the psychological power of loss aversion, a phenomenon that behavioral economists have been studying for several decades now. Most of us, you see, seek to avoid losses with greater fervor than we seek to achieve equal gains. If given a 50-50 chance of either winning or losing $100, we decline. The $100 loss looms larger than the $100 gain. For similar reasons, most people express greater interest in surgical procedures that carry 90% survival rates than in ones that carry 10% mortality rates, even though these procedures are identical. Thinking about mortality triggers loss aversion. This week we even learned that loss aversion influences putting behavior among professional golfers. When putting to avoid a bogey, golfers are more aggressive than when putting for birdie, and consequently are more likely to make their putts. Few things are more motivating than the desire to avoid losses.

Which brings us back to health care reform. When President Clinton attempted an overhaul of our health care system in the 90’s, his administration correctly recognized the need to control health care costs. Without cost containment, they knew it would be impossible to expand health care insurance to the millions of people who lacked such coverage. So the Clinton administration looked for ways to increase the number of Americans enrolled in managed care plans, which at that time had achieved some success in controlling health care expenditures.

The problem with the Clinton approach was that it made Americans feel like they were losing their traditional health care. Managed care was infamous for saying no — for denying people health care services and for limiting their choice of doctors. By taking things away from people, managed care triggered loss aversion. Consequently, the American public never supported Clinton’s reform efforts.

The Obama administration is steeped with people knowledgeable about behavioral economics, who hope to keep the public from slipping into a state of loss aversion. Not surprisingly, then, the administration has enthusiastically embraced research out of Dartmouth University, demonstrating huge regional variations in medical expenditures that have not been accompanied by any variation in health care quality. According to this research, some cities in the US spend twice as much per capita on health care as other cities without experiencing any discernible improvement in health.

Obama’s people hope that Americans will perceive health care reform as a win-win opportunity, with lower health care costs through the elimination of waste and inefficiency, accompanied by more stable and secure health care coverage. But even if the administration succeeds in assuaging the fears of the general public, they face a much stiffer challenge with the health care industry. Any success they have in controlling health care costs will, after all, create losers. If we spend less money on health care in the US, then someone in the health care industry is going to take a financial hit. One person’s waste is another person’s income.

No surprise, then, that both the insurance industry and the AMA have begun pushing back against elements of the Obama plan. These groups stand to lose money under health care reform. Hospitals are likely to lose money too, as are drug companies, medical device companies, and other powerful parts of our vast health care industry. All of these groups will be motivated to fight health care reform.

The Obama administration has made a point of distinguishing its behavioral approach to economics from the more traditional approach embraced by the Bush administration. Ironically, though, it is the Bush administration that understood how to pass health care reform without triggering loss aversion. When George W. Bush decided to push for a Medicare drug plan, he recognized that the pharmaceutical industry would wield its powerful lobbying strength against his efforts if they feared a loss of income. So he crafted a plan that benefited the drug industry. Politicians on the left criticized these concessions to industry, but it is hard to imagine the drug plan passing without such concessions.

Obama should draw a lesson from his predecessor. If he causes the health care industry to perceive his health plan as a threat to their incomes, his plan will face stiff resistance. For health care reform to succeed, people in the health care industry need to keep making exorbitant sums of money for awhile. Over time, the government can gradually ratchet down health care costs. But initially, Obama needs to reduce the number of people who perceive health care reform as a loss.

The cost will be steep. But the alternative will be more costly. We cannot afford to make reform feel like a health care bogey.

Peter Ubel is author of Free Market Madness: Why Human Nature Is at Odds with Economics — and Why It Matters (Harvard Business Press, 2009), and Director of the Center for Behavioral and Decision Sciences in Medicine at the University of Michigan.

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Hiking in Switzerland several years ago, I came across a trail that seemed to dead-end at a farmer’s gate. I looked around for a way to avoid the property, but there was none. Instead, the trail continued through the middle of the farm. I walked through the gate, side-stepping some livestock in the way (and side-stepping even more livestock manure!), until I exited the farm through another gate, back out to public property.

What a wonderfully un-American attitude towards property rights. And towards walking. The Swiss have created a culture of walking. I wonder if we can use some of the Obama stimulus money to begin transforming our culture in similar ways.

Compare my experience in Switzerland to the typical visit to the suburbs. No sidewalks on the street. No grocery stores or shops within walking distance. That doesn’t promote a culture of physical activity.

The desire to walk, or to exercise in any manner, is not just a function of individual choice. It is also a desire that is strongly influenced by one’s surroundings. A study in Salt Lake City recently showed that people who live in older neighborhoods are thinner than those who live in newer neighborhoods, a thinness partly attributable to their greater tendency to walk.

We Americans are unlikely to cede property rights to local fitness enthusiasts any time soon. We won’t be opening up our gates to walkers and bikers either.

But because of the Obama stimulus bill, many local governments are looking for shovel-ready construction projects. I hope that in doing so, they look for ways to design neighborhoods that promote physical activity.

The free market, left to its own devices, doesn’t necessarily consider what kind of neighborhoods promote our best interests. We are our neighborhoods. Our culture begins at home.

With intelligent regulations, such as thoughtful neighborhood zoning, we can influence our ability and willingness to engage in healthy activities like biking and walking. We owe it to ourselves to create healthy neighborhoods.

To read more of my blogs, and to learn more about my new book, Free Market Madness, check out my personal website: http://www.peterubel.com

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