Peter Ubel

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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Lance Armstrong will soon be competing again in bicycle races around the world, meaning that the casual biking fan will once again show interest in the sport. It also means that doping allegations against Armstrong are likely to resume. If Lance wins some big races — at his age and after so long away from the sport — some people will be convinced he has found a way to cheat. If he loses, then who cares about his age and his time away from the sport — his losses will be evidence that he must have cheated in the past and is failing at the sport now only because it’s harder to cheat.

I confess to having mixed feelings about the cheating rampant in sports like bicycling. No system will ever pick up all the cheaters. Part of me, then, thinks we should let people do whatever they want — mainline steroids, experiment with gazelle DNA, whatever — and let the fastest creature win.

But a larger part of me yearns for clean, unadulterated performances. I’d like to see what humans can do when pushed to their natural limits.

When it comes to EPO, however, I am less conflicted. I don’t see the point in banning this drug, when there are natural ways to reap its benefits.

EPO is a hormone secreted naturally by the kidneys, to stimulate the body to produce red blood cells. Red blood cells carry oxygen around our bodies. And oxygen, I have discovered, is a good thing to have in abundance when riding a bicycle up a relentless incline at high altitude.

Our bodies normally produce enough EPO to keep our hemoglobin level (that’s the blood test we doctors rely upon to assess oxygen carrying capacity) at a standard level, a level that varies a bit person to person within a fairly narrow range. A person who takes EPO, however, will experience a rise in their hemoglobin count. A person who takes too much EPO, in fact, will get so many extra red blood cells that their blood will become thick, and they will risk experiencing a stroke.

Athletes who use EPO try to increase their hemoglobin level enough to increase their performance, without experiencing a stroke. This isn’t too hard to do. There’s a good margin of error.

In fact, athletes have found natural ways to increase their hemoglobin supply. The simplest way is to simply train in high altitude. When our bodies are regularly deprived of oxygen, our kidneys squeeze out EPO so we can absorb available oxygen more efficiently. Some athletes, rather than train at a high altitude, sleep in specialized tents that mimic the conditions of high altitude.

Do you see why I’m ambivalent about EPO? We live in a strange world, where it is wrong to boost your hemoglobin supply by taking synthetic EPO, but okay to do so by sleeping in a special tent. We live in a world where you’re banned from sports if you live in Texas and inject EPO, but rewarded if you live in the Himalayas and benefit from your body’s natural EPO production.

I think we should lift the ban on EPO and make rules that set limits on hemoglobin levels. Athletes will be banned from performing if their hemoglobin exceeds some level, put on probation if it is in some gray zone, and allowed to compete if it’s below the accepted cutoff. Professional athletes would monitor their own hemoglobin, take EPO or sleep in a specialized tent if their hemoglobin falls below their target, and drain some blood out of their system if their hemoglobin rises too high. With this system, everyone’s hemoglobin will sit somewhere in the safe zone, whether it gets there naturally or unnaturally, and we wont have to worry about somebody having an advantage over anyone else. Nor will test monitors have to monitor that people have found ways to mask the use of synthetic forms of drugs like EPO.

I’m sure such a system would be more complicated than I’ve laid out here. Heck, this is a blog post, not an academic paper.

But isn’t this idea worth serious consideration?

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If President-elect Obama wants to know the challenges he can expect to contend with in his first 100 days of office, his “honeymoon period,” he need look no further than the state of Michigan.

I’m not talking about what he can learn from Michigan about unemployment, where we are #1!

I’m not talking about lessons he can learn from Michigan about relations with the Middle East, given the large population in Michigan who originate from that part of the world.

I’m not talking about any of these things. Instead, I’m talkin’ football…Wolverine football, and the pressures that come to those who take on new leadership positions in a world saturated with 24/7 media.

The University of Michigan football team brought in a new leader this year, Rich Rodriguez from West Virginia, with expectations that this innovative coach would turn our good football team back into a great one, one that would regularly compete for national championships.

The parallels between the situations facing Rodriguez and Obama are impressive. Like Rodriguez, Obama will come to his new leadership position amidst expectations that he will return the United States back into the world’s premier super power.

Both Rodriguez and Obama face a flat world. The globalized economy is going to be a huge challenge for Obama, with no single country able to dominate the world’s economy any more. Similarly, the flattening of the college football world is a challenge for Rodriguez, a world in which formally dominant programs like Nebraska and Notre Dame find themselves struggling to keep up with the increasing number of colleges investing huge money in their football programs.

Both Rodriguez and Obama must also contend with a vicious 24/7 news cycle that feeds on controversy and that promotes impatience. ESPN and CNN need material to fill up time. Talk radio stations–covering sports or politics–have lots of time to kill too, and consequently don’t pause for a moment to absorb new information before pronouncing something a success or failure–how could he have chosen so and so as starting QB or as head of the Justice Department!?

Is it possible for a leader to thrive in this environment? And to survive, do they have to experience immediate success?

Recent experience in Michigan suggests that success doesn’t have to be immediate. Rodriguez had a horrible first season at Michigan. Unprecedentedly horrible. The Wolverines lost to their arch rival, Ohio State, for the umpteenth time in a row, broke their record of successive years in a bowl game, and even lost to the University of Toledo. (Toledo!)

The 24/7 media should have chewed Rodriguez up and spit him out by now, based on the way they’ve dealt with other people who don’t garner immediate success. But by and large, they haven’t. And it’s illuminating to think of why they’ve laid off so far, and ponder how that might payoff for Obama when he becomes President.

You see, everyone knew that Rodriguez did not inherit a team ready to fit into his new scheme. He didn’t inherit a quarterback compatible with his offensive system. (Heck, he didn’t inherit a quarterback compatible with any division 1 team’s system.) To make matters worse, he inherited only one returning starter on the entire offense. Defense looked like it would be Michigan’s strength, but how strong can a defense be when it is exhausted by the end of the first quarter, getting no chance to rest because of the ineptitude of its offense?

We Michiganders (yep, that’s what we’re called) knew things would get worse before they got better. So far we have been willing to give Rodriguez a chance to demonstrate what he can do when he has had time to implement his new system, with people he has recruited.

I don’t know how long Rodriguez can continue to struggle before people start calling for his head. Another 3-win season and many Wolverine fans will thirst for blood. But show fans some progress, and they’ll wait at least one more year.

Like Rodriguez, Obama has a few returning players–Gates at defense, and those nine folks over at the Supreme Court–but he’ll be bringing in a new team, ready to make dramatic changes from the Bush Administration. And he will inherit insanely difficult challenges. People know that things are broken now, and won’t be fixed overnight. They even expect things to get worse before they get better. This is all to Obama’s advantage.

Let’s hope the hunger of our 24/7 media, and the insatiable appetite of the blogosphere, doesn’t lead too quickly to calls for Obama’s head when things don’t turn around in 100 days.

So far Rich Rodriguez has survived the rigors of the passionate Wolverine fan base. He has managed people’s expectations, while doing everything in his power to turn things around.

Let’s hope Obama can continue to manage the public’s expectations of what he will accomplish in his first term as president.

Although the challenges Obama faces tower over those facing Rodriguez, Obama does have one thing in his favor: unlike Rodriguez, he doesn’t have to compete again in Ohio for four more years.

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This year, for the first time, the Wimbledon Championship offered equal prize money to men and women, joining the U.S. Open more than 30 years after that tournament recognized the importance of equality between the sexes. Unfortunately, neither tournament has joined the idea of equal pay between sexes with the notion of equal play. Women’s championship matches persist as best-of-3 sets, while the men battle away for as many as 5 sets. This inequality bothers me, not only as a feminist, but also as a tennis fan, for it leaves me with no hope of witnessing an epic women’s final.

Consider the Men’s Wimbledon’s final from last July, a glorious 5-setter between Rafael Nadal and Roger Federer. If that had been a best-of-3 match, Nadal would have cruised to a quick 2-0 victory, and the final, rather than being a battle-for-the-ages, would have merely been lopsided evidence of Nadal’s new dominance. However, because the men played best-of-5 sets, Federer was able to show his resilience and demonstrate to the world he can still play inspired tennis. We tennis fans were rewarded with a gargantuan match, with stirring play across both sides of the net, the winner in doubt for well more than three hours.

Contrast that with the all-Williams Women’s Final. The final did not lack for excellent tennis play. Unlike previous matches between these sisters, both of them brought their A-game to this final, and the match was a joy to watch. But after a mere two sets, barely half way through my breakfast at Wimbledon omelet, the match was over. Great tennis, no doubt. But unfulfilling.

If only these women had played a best-of-5 match like the men. Would Serena have made a comeback to win the third and fourth sets? Would Venus have then regained momentum to win the fifth set? Or would Serena have continued in her remarkable comeback?

We will never know.

In the old days, people mistakenly believed that women were too frail to play 5-set matches. This mindset allowed us to go for decades without a women’s Olympic marathon. This mindset still causes us to have a men’s decathlon versus a women’s heptathlon. And worst of all this week, as the US Open begins once again, it has left us tennis fans with no realistic chance of watching an epic women’s final.

Time to fight for equal playing rights for women.

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The facts seem indisputable. After a courageous battle against cancer, Lance Armstrong inspired millions of people - bike aficionados and those who don’t know a pelleton from a crouton - by winning the Tour de France an unprecedented seven times in a row.

As one of the millions who have been inspired by Lance - and who has beaten Lance numerous times (in feats of my imagination) during my weekly bike rides - I cannot dispute Lance’s biking prowess. Nor can I deny his fearlessness, fearlessness in the face of cancer and in the face of stiff bicycling competition.

But I can dispute the notion that Lance’s battle against cancer was a superhuman feat, that his ability to survive metastatic cancer arose from the same mental and physiologic freakiness that allowed him to dominate the most physically demanding event in all of sports.

Folks: I know that Lance Armstrong is an amazing guy. But please don’t give him more credit than he is due. Lance Armstrong fought against his cancer, no doubt. And this fight required strength, which he had in spades.

But his survival was not some freakish coincidence; it wasn’t a matter of his biology overcoming and otherwise relentless tumor. Lance Armstrong survived, in large part, because he came down with one of the kinds of cancer that happens to respond to treatment. And his cancer was cured because Lance acted the way most people would act - he sought out treatment, and suffered through the miseries that such treatment brought upon him.

As I discuss in my book You’re Stronger than You Think, few people, when faced with life threatening but potentially curable cancers, lie down and die. Few people give up without a fight. And cancer survivors don’t typically survive because they are tougher or stronger than other people. My gosh. What would such a truth mean for those who die of cancer: That they are weak? That they didn’t fight hard enough? That they weren’t enough like Lance?

In my book, I write about several people who confront serious illnesses, like cancer, and manage to thrive. The people I write about are inspiring and deserve our admiration. But they are not superhuman. They are, simply, human. And being human often means being endowed with unbelievable reservoirs of strength. Most of us underestimate our own strength, making the human seem superhuman.

I’m inspired by Lance not because he survived cancer, but because of the phenomenal discipline he showed in winning seven Tours. That feat required strength that most people will never have. Out on the cold roads in early spring, he had to know that he could take it easy once in a while without jeopardizing his chance to win the Tour. Did he really need to push so hard up every mountain every day?

But time and again, Lance didn’t let that type of thinking dissuade him from his efforts. He rode up those mountains. Often he rode back down and rode up again on the same day, to the point of sickness and exhaustion. Day in, day out. What relentless effort!

Let’s show more appreciation for what is truly great about Lance Armstrong - that he was not only supremely talented, but was also an overachiever.

And let’s show more appreciation for the millions of people diagnosed with cancer every year, who exhibit so much strength in the face of their illness, some of whom live and some of whom die, but few of whom give up without a fight!

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