Wednesday, August 28, 2013

He's a Man You Must Believe

I never know how to take self-reports about information sources...it's probably not a very good idea to take them at face value.

But for whatever it's worth, I'm a bit intrigued at one bit from today's new Kaiser poll. It turns out that of the various sources of information about the ACA, people say they trust "your doctor or nurse" the most (quite sensibly, people claim to trust "social networking sites" the least, although that they say that doesn't, again, mean it's actually true). It's not anywhere close to the most used source; only 22 percent say they've recently heard something about ACA from "Your doctor or another health care professional." But what they hear, they say they trust.

What all this makes me wonder about is whether doctors are in fact a significant source of misinformation about Obamacare.

It's pretty unlikely, in my view, that doctors are particularly well-informed about the ACA -- at least, about the kinds of questions that consumers would have. Why should they be? I suppose some they would know about some of the cost-control reforms, at least to the extent that it directly affects them. But the whole exchanges/subsidies/mandate portion of it doesn't really have much to do with doctors, at all. At least not directly.

Meanwhile, doctors strongly tend to be Republicans, and I'd guess that doctors probably fit comfortably into the Rush Limbaugh listening demographic. The odds that doctors have heard, and would believe, various Obamacare myths strikes as very high. Are they then passing those myths along to patients (and others they meet)? And are people who might dismiss something if it was email forwarded from Uncle Larry assuming that if a doctor said it, it must be true? If so: how much of the misinformation out there does it account for?

Obviously, this is totally speculative. Any step in the logic I'm setting out here could be dead wrong, including the assumption that doctors are relatively uninformed about health insurance reform. I'd sure love to see a study about it, though.

16 comments:

  1. I think there's something more important here than ideology or propaganda, namely, do doctors think the ACA is a net benefit to them?

    I suppose some physicians may perceive a benefit from increased volume, but mostly I would expect them to see the ACA as a likely negative. Physicians in socialized medicine systems aren't as well compensated; beyond that many other issues like the activity of the IPAB or 'Doc Fix' (IF!) represent potential hurts to physician compensation.

    You don't need right-wing manipulation for physicians to oppose something that they (probably rightly) assume is going to leave them somewhat worse off than the status quo.

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  2. Meanwhile, doctors strongly tend to be Republicans, and I'd guess that doctors probably fit comfortably into the Rush Limbaugh listening demographic.

    I'd like to see some data on this. If doctors do tend to be Republican, I'm curious how long this has been the case. My impression is that their opposition to health-care reform runs deeper than simply partisan identification. I read a book recently on the history of health-care reform in this country, and one thing absolutely clear was the opposition it engendered from the medical community at every turn. FDR wanted to add health-insurance provisions to Social Security but backed down due to pressure from the AMA. The medical establishment also played a strong role in the destruction of Truman's health-care initiative. They even opposed private insurance at first, but eventually made peace with it once they realized it was their only hope of stopping national health care. For whatever reasons, the American medical community has long found health-care reform deeply threatening to its interests. This may in fact be a contributing factor to the party identification of most doctors.

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  3. A huge part of this probably depends on the structure of how individual doctors are employed. If you are a doctor in a private practice major reform could mean massive changes to your practice i.e. the small (or not so small) business you own. If you work for a big health provider, which more and more doctors do, big changes in the healthcare system probably affects another department in your big organization. You just keep on seeing patients.

    Take the issue of the uninsured, if you have your own private practice you can quite literally just ignore them and not see anyone without coverage from the insurers you like. It doesn't necessarily impact your business at all. If you work for a big network you probably hear about how the network is facing rising costs from more and more treatments in the ER or defaults on medical debt or whatever. Meanwhile you might hearing about the great opportunity "we have" to serve all these new customers under ACA. The same way employees and any company hear about how the company is doing. As a result ACA could seem like a good reform because it helps your employer and thus you.

    I've always thought that the movement from doctors going into business for themselves via private practices to doctors working for big organizations was a major reason why the AMA supported Obamacare.

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  4. I unfortunately can't remember where I read this (probably Jonathan Cohn posted something on it c. 2009!) but it's worth noting as well that the more specialized a doctor's field, the more Republican they vote. GPs aren't Republicans. Nurses aren't. Non-surgical specialists are somewhat Republican, and surgeons are very much so. By a shocking coincidence, these divisions according to medical status correspond strongly with divisions in salary, gender, and race.

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    1. Surgeons add another wrinkle, though: personality. Surgeons really are a different breed of cat than GPs, and in ways that would lead towards conservativism: fiercely individualistic, amazingly high self-esteem, and, one might go so far to say, a pretty strong affinity for a "pecking order" view of the world.

      All this is based on my limited experience with surgeons (I only know one as a personal friend, and have been operated on 3 times), so YMMV.

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    2. Most of what I know about surgeons and other doctors I learned from watching medical sitcoms, and they agree with you.

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    3. Here's my anecdotal take. I have a parent who's a doctor (OBGYN), and so I grew up hearing about the institutional state of medicine and came/come in contact with many of the parent's doctor friends. The parent is a pro-choice moderate Republican. The friends varied from Republican to Democrat, but tended to the moderate Republican/centrist Democrat side

      A huge part of this is generational. Decently successful to very successful middle-aged and older doctors, even though they might see flaws in the system, did manage to succeed within it, feeling both sufficiently fulfilled and often lucratively compensated. These older doctors are the ones who've gained prominence and respect in the field, and they're different from doctors who are solely researchers/professors or who have become public policy advocates/specialists. Doctors are intelligent professionals but they don't think systemically about medicine as either a private business or a matter of public health policy. It's not part of their training, and there's a reason hospitals and practices have layers of administration, management, and accounting apart from the doctors. Only a small subset of doctors ever transfer over to taking on substantial management duties and learning to think analytically about the whole chain of actors in the medical business.

      The issues that these doctors have faced most directly in their everyday experience over the last decade (or two) and thus in their perception are 1) rising medical malpractice insurance costs (hence the prominence of calls for "tort reform" as a talking point), 2) fluctuating and uncertain Medicare/Medicaid reimbursement rates, 3) a continuing onslaught of promotions and opportunities from pharmaceutical companies and device manufacturers, and 4) new imperatives from hospital administrators and from government promotion/regulation to adopt electronic medical records. It is hard for an everyday doctor to clearly separate these trends and pressures from the main issues of the ACA, as far as they understand them. They can see a need for change or rationalization, but they also tend to distrust schemes for change as more trouble than they're worth.

      In particular, the adoption of electronic medical records has been a huge practical headache for the older generation of doctors, used to doing things one way without so much technological mediation. It puts them in a seriously bad mood about their own practice's amount of bureaucracy, and so they are deeply susceptible to any critique of the ACA that focuses on worries about it as a coming bureaucratic nightmare. And to the extent that they already feel like they're dealing with a bunch of hassles in adapting to a new era, they're not looking forward to the nuisances of the ACA. So that's my sense of one prominent strand of doctors' disposition toward the ACA.

      Notably, that's without even getting into the ACA's key -- but so little discussed by either the Left or the Right -- income and investment tax increases on high-earners. Many doctors are more aware of these than most people seem to be in the general public. I can't imagine they discuss it with their patients, but it colors their emotions toward the ACA.

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    4. Thanks for the thoughtful detail, Anon 9:58. In particular, I wouldn't have realized what a hassle electronic records might seem to some people; no doubt because my medical care is through a big regional hospital that has long faced its own incentives to make records comprehensively integrated and accessible.

      More family anecdota, since they line up with the trends under discussion: my grandparents worked in public health -- first outside of Cape Town, then (on the education side) in Boston, then in rural North Carolina -- and thought the health care system here entailed a dreadful waste of human potential; they were always advocating for greater availability of basic preventative care, and certainly would have strongly supported ACA. My aunt and uncle work in health administration: my uncle was the head of Massachusetts HealthConnector and has been consulting with other states that are trying to set up their own exchanges. My uncle on the other side is a Canadian-born anaethesiologist who makes tons of money for working three days a week and thinks that most people who vote Democrat are lazy parasites exploiting a system rigged in their favor.

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  5. Also, sometimes you've said you like it when people acknowledge the song lyrics you quote in your headers. So, I do hereby take notice; and I further suggest that you continue to use Beatles lyrics if you would like people to recognize the songs.

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    1. Yes, I do appreciate it! Thanks!

      I was trying to use something from Dr. Luther's Assistant, but that song really does not have a relevant bit to use for this post. Plus no one would have noticed.

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    2. I'm trying to relate the trend of calling Obamacare things other than Obamacare to "changing words while the ink is still tacky" but that doesn't quite do it.

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    3. Correction: At least one person would have noticed. But yeah, it didn't work.

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  6. As an aside from the doctors angle, I'd go with librarians in re: who I'd trust in re: the ACA.

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    1. Librarians are about the only people I don't know who I DO trust.

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  7. "Doctor Robert, he's a man you must believe,
    Helping everyone in need
    No one can succeed like Doctor Robert"

    So you know somebody got it

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  8. Oh, and ... anyone else remember the article (maybe also about how people most trust their weatherman about climate science, even though weather forecasting has nothing to do with the kind of structural issues involved in climate science? That seems like a pretty direct parallel to the phenomenon that is the (actual) topic of this post.

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