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The psychology of healthcare reform

NICs, PUFs, PICs and NUFs--these funny-sounding acronyms hold some truths about the psychological reasons that people react so strongly to the healthcare reform debate.

The House has passed the first comprehensive reform package of the health insurance industry in decades, which is now up for debate in the Senate. This is a highly complex issue, but there are some quite basic reasons why it's so difficult to accomplish significant reform, and in part these have to do with psychological responses to change and uncertainty. 

A few years ago I was fortunate to work with a couple of organizational consultants, and they introduced me to the concept of NICs and PUFs. These funny sounding acronyms give insight into why health care reform is so difficult for many people to support. (And once you have this shorthand for thinking about scenarios, you find ways that they apply in all aspects of life.)

The two acronyms, and their counterparts PICs and NUFs, refer to the likelihood that something will happen, whether the impact with be positive or negative, and how quickly the impact will happen.

PICs: Positive, Immediate and Certain. This is the best case--a good impact will be for sure happening to me soon.

NICs: Negative, Immediate and Certain. This is the worst case--a bad impact that will surely happen, and right away. People instinctively avoid these as much as possible.

PUFs: Positive, Uncertain and Future. Something good may happen, but if it does, it will be in an indeterminate future, and I don't really know how good it will be if it does happen.

NUFs: Negative, Uncertain and Future. The opposite of course, that something bad may happen at some point in the future, with an uncertain degree of badness.

Applying these to the health care debate, they clearly illustrate why there is resistance to reform.

The consequences of reform in terms of money-out-of-pocket, quality of care, and choice of care are all unclear for most people, naturally so since the changes are complex. It's therefore unclear whether the changes will be positive or negative in nature. Depending on one's financial situation, job security, and satisfaction with current health care service, one may be inclined to see the change going more in the positive or negative direction.

The battle over the public option partly revolves around whether people will get bumped off their existing plans and onto a government plan. This would represent potentially a large scale change, and again may be seen positively or negatively depending on one's circumstances. But when that switch may happen is unclear. Would the introduction of the public plan cause an immediate sweeping change as employers dropped their private insurance for the public plan, or would the status quo hold? Since this is unclear, people have differing opinions about how it will play out.

People who see PICs in health care reform obviously support it--they think it will bring positive changes, quickly. This may be because they stand to gain personally, or see immediate benefits for those who are currently under- or uninsured.

People who see NICs are against reform, believing that it will have immediate negative results, whether for themselves or others.

PICs and NICs are going to be hard for politicians to sway as they are pretty entrenched in their positions (anchored by the Certainty and the perceived near-term consequences). Immediate impacts, whether positive or negative, often have a more powerful influence than ambiguous longer-term ones. That's why dieting is difficult--immediate pleasure of a cupcake now vs possible ambiguous connection to expanded waistline later. It's also why saving is difficult--the benefits in the far of future feel less compelling that buying the latest gadget or trinket today.

It’s the PUFs and NUFs that are the swing votes in the health care debate, and here we are tending to see the “devil you know is better than the devil you don’t” dynamic playing out. With something as literally life and death as health care and insurance, the glass-half-empty NUFs tend to outweigh optimistic PUFs. If there is a chance of a negative result that you can’t define or predict, then it can seem safer to stick with the status quo rather than hold out hope for an ambiguous improvement at an indeterminate point in the future.