Why We Believe We Are Entitled to Health Care

I learned the Supreme Court voted to uphold Obamacare today while I was in a brainstorming session for a drug that will launch next year. I had the same thought I've had on other occasions when people define the "right" to health care: how can someone have a right to a product that has just been invented, or to a skill that certain individuals study for decades to acquire and perfect? Of course, if we want to be strict with our language, Obamacare doesn't give anyone a right to health care, it creates a new entitlement to health care.

I've always had a problem with the notion of a government entitlement. It implies, to my ears, that the State determines what people need to get by in life, and then sets out to give it to them. And that the people have to be vigilant in making sure that they get what's coming to them. I hear, in my head, a smart but whiny teenager, "If my sister is getting a new car, then I'm entitled to one, too!"

But leave aside my grumpy dislike of the word: should there be an entitlement to health care? And what would we include (and exclude) within that entitlement? A lot of people clearly believe there should be a very broad health care entitlement, including medicines like contraception that stretch that entitlement far beyond life-and-death issues. So, are we entitled to all pharmaceutical products? Even this one? Is every surgery part of that entitlement? Even this one? Suddenly it becomes hard to find the line.

I kept sitting in my meeting, thinking about these issues and (as it happens) eating a wonderful chipwich. My mind went to FDR's Four Freedoms, and specifically the Freedom from Want. That idea is largely defined as implying a right to adequate food, clothing and shelter, and sometimes to the right to a job that pays a living wage. It seems odd, first of all, that we would push for universal healthcare before we would push for universal access to those more basic elements of survival. But it also seems apparent, if we defined a food entitlement as broadly as we define the health care entitlement, that we would be enshrining universal access to chipwiches into law. Of course, people like me would love that, and I'm sure the chipwich people would love that (and clearly, the pharmaceutical industry was bullish on the notion of increasing their potential market with Obamacare), but that doesn't mean it makes economic or practical sense.

Forgive me for going on, but I'm trying to make the argument that we have very muddle-headed thinking about what a health care entitlement should actually do, and what it should (or shouldn't) cover. I'm going to assume that my chipwich analogy has you convinced that we can't give all people access to everything that falls under the header of health care. But why isn't this instantly apparent to people?

Well, I'd like to offer two completely speculative suggestions. The first is that health care consumption is much more passive for most people than is their consumption of food, clothing, shelter and other basic necessities. If you need food, you go out and buy what you think is best and what you can afford. Even if you are on food stamps, the choice of food and the act of getting it is still in your hands. But taking charge of your health in a similar way is almost impossible. You very rarely even know what you need until someone else tells you: if you feel "bad", you go to a doctor who pronounces what you need, and then hands you a piece of paper which you docilely take to a pharmacist, who hands you a bottle of nondescript pills that you assume will do what everyone told you to do. And most of this is paid for by your insurance, so you don't even really know what it costs. Essentially, your health is already basically someone else's problem, so taking the step of saying it is the government's responsibility isn't really that dramatic.

The second possibility is that improving our health through popping pills or invasive surgery is evolutionarily novel. The psychologist Satoshi Kanazawa has developed the theory that intelligence evolved to deal with evolutionarily novel problems, the type of things we wouldn't have to deal with every day. As he puts it:

We know what to do when it comes to mating.  We know what to do when it comes to parenting and learning a language associated with other people. All these things our ancestors did already have ready-made solutions in our brain, but occasionally there are novel problems that required our ancestors to think and that’s how intelligence evolves. Some people who could think and reason and solve these evolutionary novel problems did better occasionally, so my contention is that intelligence evolved to deal with novel problems and as a result more intelligent people are more likely to recognize evolutionarily novel entities and situations.

So, you'd expect that, faced with the proliferation of new treatments, intelligent people would be more comfortable dealing with them and coming up with ways to make them more accessible. But he continues:

The key part of the equation is that intelligence leads individuals to seek novel solutions and as a result they become more likely to adopt novel preferences and values, so intelligence makes people do unnatural things.

I read this to imply that, in the face of evolutionarily novel situations, people are willing to try something different, but we aren't automatically going to pick the right or most workable solution to the problem we face. People generally know what to do to get food, clothing and shelter, but the novelty of accessing health solutions might make us willing to consider "unnatural" alternatives.

To go back to food analogies: we would never say that everyone has the right to prime rib and lobster every day, because we all intuitively understand we'd go broke. But the novelty of health care makes us blind to that simple truth. Of course, eventually economic reality will overwhelm our confusion and the good intentions that have led us to this point.

Is Buzz Dead?

In the digital world, you are never very far from the masses turning on you. Anything that gets popular seems guaranteed to spark a backlash. (For a good example, consider Stop Kony.) But could the legions of skeptics and critics out there actually overwhelm the initial benefit of publicity and viral popularity? That's the entertaining thesis of this post, arguing that buzz is dead. The author, Richard Rushfield, extends the theory from the obvious realm of pop culture (where backlashes against emerging trends are as old as disco) to politics. Rushfield observes: 

A poll today revealed that Mitt Romney’s favorable ratings have risen over the past few weeks, during a time when he’s largely been off center stage.   There’s been the Bain brouhaha, but Romney himself has mostly let others take on the fight, with Pres. Obama and Romney surrogates occupying the foreground, while he’s taken a step or two back. Compared to the primary battles when he was standing in the floodlights every day. 

Likewise, I’ve seen it demonstrated before that Obama’s approval rating tends to go up when he was out of the limelight, during the Republican primaries or when he’s been on vacation for instance.   

Looking at this it seems very clear that there is no such thing as positive attention in the Twitter age; that anyone who sticks their head up is going to just have it picked apart by 100,000,000 gnats.  The internet has largely become a roving lynch mob and you can’t stop a lynch mob with comedy GIF’s.

Rushfield then goes on to suggest a few antidotes to getting caught up in an anti-buzz backlash, including appealing to a group that isn't interested in broader societal acceptance (what he calls the "Game of Thrones model"), being intentionally ironic in gaining buzz in the first place, or just being really, really good. I'd note that none of these models seems particularly applicable to politics, the last in particular.
But why should we be so quick to turn on the hot trends of the moment? Why, I'm so happy you asked! It just so happens I have a theory:


1) Social media elevates people (or, in the case of politics, sound bytes) too quickly: There have always been one-hit wonders. But now social media amplifies the effect even further, as videos go viral and people want to share the latest thing. But the problem is there is no deep loyalty to these artists, and so when the backlash of criticism comes no one has much reason to defend them. That's why I would guess Gotye isn't going to be selling out arenas in three years, while the Black Keys will. The latter have been building a fan base for a long time, and those people will sustain them even when the snark inevitably starts building up. (A quick aside on how this works in politics: a campaign puts out a "talking point" that tested well in a focus group. In the real world, it gets promoted by that side's partisans, but the opposition attacks it for being artificial and the vast majority of America either doesn't care or else agrees that the point is phony. Talking point goes away, partisans complain that their campaign doesn't know how to communicate.)


2) Attention is a zero sum game: People only have 24 hours in a day. Every time you watch a stupid video because it is popular, you get annoyed: someone stole that time from you! Even worse, other people are now going to watch this "popular" thing when they could be watching some much better and underappreciated thing that you like. So, before you move on, you attack that awful thing that wasted your time. 


3) People don't always want to like what you like: Sure, if you post that your mom just got out of the hospital or put up some amusing meme, people will probably "like" it without concern about their digital self-image. But a lot of your friends probably think the bands you like, the politicians you like, the clothes you like and the celebrities you like are boring, stupid or worse. So, through a combination of wanting to assert their originality and wanting to passive aggressively criticize your taste, they post a snarky comment. Of course, not on your page (because that's how friendships end) but on the video's page.


That combination is deadly to marketers and promoters trying to build buzz on social networks. The interesting thing, when you're in a marketing brainstorm meeting that flits on to social media, is that most marketers ascribe to "consumers" behavior that they would never imagine themselves doing. Would you "like" Weight Watchers on Facebook out of solidarity with your dieting friend? Aren't you at least a little skeptical of any post that includes, "Everybody make this your status today to show the world..."? How often do you check out an artist that your friend likes, versus the number of times you roll your eyes and congratulate yourself on your superior taste? (Well, that last one might be mostly me, as my wife says I'm a music snob...)

Bottom line: you can, if you understand social media and the Internet well enough, manufacture a surge in attention for a brand, a cause, or a piece of content. What you cannot do is trick people into liking it once they see it, and you might, by pushing it too hard and too fast, alienate someone who might have eventually come around if they hadn't felt it was overhyped. Buzz isn't dead, but it is dangerous.