Wish List for 2020 US Presidential Polling

Here are a few observations before stepping back onto to the sidelines to watch critiques of 2020 US presidential election polling methods.  Some of these points are being expressed elsewhere, even if they aren’t necessarily noticed much.  There’s a perception that polls failed in 2016.  While it’s true they were accurate, in aggregate, they certainly didn’t predict the actual loser- because she came up short in the electoral college anyway.

Attention to this topic put pollsters in a defensive stance, and in May 2017, AAPOR (American Association for Public Opinion Research), issued their evaluation of what wrong.  It is thorough and useful.  Sound scientific methods, when applied without practical knowledge may produce bad results.  What can be done differently in 2020?

1. Fund high-quality polls in the few states that matter

The implicit sample frame for US presidential polling is all 50 states.  Except for a few key primary races however, most of them are irrelevant.   Well-funded public polling was very scarce in the most important states during the last days of the 2016 campaign: MI, PA, WI.  As Pew Research has warned, “high-quality state-level polling in the U.S. remains sparse and underfunded”.

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Marketing Brief: Prescribe Me a Stronger Placebo!

The placebo effect is mysterious and frequently overlooked.  Could it be leveraged in better ways?  Not all placebos are created equal.   In a 2018 review in Annals of Neurology, Matthew Burke of Sunnybrook, in Toronto, cites how an IV placebo is more effective than an oral medication placebo in lowering hypertension.  His study concerns transcranial magnetic stimulation (TMS), demonstrating it can produce a high proportion of placebo responses.  Placebo treatments appear to be particularly effective for subjective symptoms, such as depression and pain.  These are both targets of TMS.

The derivation of the word ‘placebo’ is Latin, meaning ‘I will please’.  Their existence is most commonly acknowledged in pain management.  If presented with the choice of prescribing opioids or TMS for chronic, non-malignant pain, which is in fact the better route? Opioids are not effective, and lead to iatrogenic effects from dependence.  Even sham TMS might be an effective placebo alternative, producing beneficial results, with no harm. Of course, this leads to an ethical dilemma, since administering placebos potentially introduces dishonesty into the clinical relationship.

Ethical concerns are only the beginning of questions raised by considering placebos.  While they may be prone to working for mood symptoms or pain, it is hard to know for whom.  The patient characteristics associated with a favorable response are difficult to predict.  There’s a web of informed consent considerations.  Knowing a placebo might be prescribed is one matter, while withholding such knowledge at all is a more serious situation.  There’s also the risk of a nocebo response, when an inert intervention nevertheless exacerbates symptoms.

Psychologists tend to categorize placebo (and nocebo) research within the broader study of non-specific effects.  In any therapeutic interaction, qualities such as empathy, warmth and positive regard are associated with better outcomes – sometimes perhaps even more than the technical content of the treatment.  This is because the power of placebos relies on patient expectancies.  Positive beliefs can produce beneficial effects on their own.

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Hidden Costs of Healthcare (Whither the Withering Brokers?)

Broker commissions are one of the “occult” drivers of cost when USAmericans purchase health insurance.  They are occult in that they are hidden from view- not because there is something automatically sinister afoot.  In fact, brokers have a valuable role.  Like in any situation with information asymmetries, they possess knowledge that may not be readily available.  Purchasers can be better off by relying on their skills for sourcing details about cost and coverage.  A good broker ideally sources a variety of alternatives, in order to come up with a responsive offering.

Frequently, healthcare insurance purchasers don’t see cost of the commissions paid.  Brokers receive these from the health insurance company, out of sight.  The cost is bundled into the monthly premium.  Shrewd employers know how to ferret out details about this, using techniques like those enumerated by Health Rosetta.  Beyond actual commissions, a policy contract can be layered with various incentives or discounts, ones that may not always align with the financial interests of the covered life.

Individual purchasers are caught in a situation that is different than employers, since they possess less bargaining power by not being in a group.  Their predicament is evolving.  The Affordable Care Act (ACA) requires 80% of premiums go to actual healthcare.  A limit of 20% is left for administrative costs, including marketing and broker commissions.  This is one reason why individual purchasers are less attractive for brokers.  (One may ask why even 20% is necessary, but the administrative efficiencies of USAmerican healthcare are immense.)  Employer-sponsored insurance can produce bigger commissions. When ACA was created in 2010, some predicted that the incentive for brokers to participate would vanish.  This hasn’t occurred, but there is a progressive decline in the number of agents participating in ACA.  Modern Healthcare reports that 49,100 agents participated in 2018, down from 79,604 in 2016.  Still, they were supporting about 42% of exchange purchasers.

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