How Can We in Public Health Better Communicate Risk?

Ashish Jha: 00:00:00

Hey everybody. Ashish Jha here from Providence, Rhode Island on a sunny afternoon, and we are back for a moment in health the podcast where we talk about one data point, cover one study and then answer one question. And I'm going to go ahead and get started, and I want to talk about one data point. And the data point I want to bring up today is 62% six in 10, 62% what is that number? That number comes to us from actually Miami, Dade County, the seventh largest county in the United States, with about 2.8 million people, 62% of people in Miami, Dade County, get their health insurance either through Medicaid or through the Affordable Care Act. And by the way, if you throw in Medicare, another government program, that number goes up to 82% but let's stay focused on 62% because right now, Congress is hotly debating what to do with health care spending, and various proposals that are in the House bill, and other proposals that are being thrown about are going to cause people with Medicaid to lose health insurance. Is going to do cuts in Medicaid, and there are proposals to end a lot of the ACA subsidies. And if you think about who's going to be hurt the most, you're going to look at places like Miami, Dade County, where 62% of everybody gets health insurance, either through Medicaid or through the ACA subsidies. Staying with this number, I want to actually talk about a couple of other things that I think are interesting. By the way, a lot of the data I'm going to be data I'm going to be talking about come from the Kaiser Family Foundation. But if you ask the question about ACA subsidies, a lot of them are set to expire. If you ask the question, which states have the highest proportion of people on ACA plants, this is, again, from the Kaiser Family Foundation. I think this is pretty interesting looking at non elderly adults, just non elderly adults. Number one state for ACA plans people on ACA plans is Florida 28% number two is Georgia at 16%

Ashish Jha: 00:02:14

numbers three and four are Texas and South Carolina at 15% each. And then Utah is at 14% really reminding us that so many of the people who've benefited from both Medicaid expansion in the states that have done it, but also the ACA plans are people living in red states. Last point I want to mention is that right now, there's a specific bill that Congress is considering, the CBO, the Congressional Budget Office, the nonpartisan Congressional Budget Office just came out with their assessment that about 10 point 9 million or about 11 million Americans are going to lose their health insurance. And as we have talked about on this podcast before, health insurance turns out to be really important. Not shocking, but it is true. Health insurance turns out to be really important for helping people stay healthy and preventing things like getting really sick with chronic disease, cancer, heart disease, and ultimately dying. So the data on that is very good, and so 10 point 9 million people losing health insurance would be not so great. Okay, that's your data point 62% of people in Miami, Dade County, are on either Medicaid or ACA plans.

Ashish Jha: 00:03:22

Move moving on to the study of the week. The study of the week comes from some colleagues at the Harvard Medical School and the Health Care Health Care Policy department, and this study is entitled, Medicare Advantage denies 17% of initial claims. Most denials are reversed, but provider payouts dipped 7% this is in the June 2025, issue of the journal Health Affairs. And let me talk about this study and why I think it's super interesting. So Medicare, the program that we have for the elderly and for the disabled, has seen a remarkable transformation the last 15 years. It has gone from the traditional Medicare Fee for Service program to really being overtaken by Medicare Advantage, where private insurance companies run Medicare A majority of seniors now are in Medicare Advantage programs. And one of the complaints physicians have had, there are a lot of policy issues with Medicare Advantage we can talk about, but one of the big complaints physicians have is the denial of claims, that there has been a frustration that a lot of claims get denied and unnecessarily so. And what this study does is actually tries to quantify that and finds that one in six claims by physicians. So I'm talking about a doctor's visit, a lab test or X ray, a referral you might need, one in six of those gets denied by Medicare Advantage plans. Majority of them end up getting reversed, because obviously, physicians will appeal those, and a majority of them end up getting reversed, not all of them, and sometimes physicians just get super frustrated and just dropping it all together, and that ultimately leads to lower payouts for physicians. It saves insurance. Companies money, but at the end of the day, leads to a lot of people probably not getting key services they need. Let me take a minute to talk about this, because it has been a source of incredible frustration. Insurance companies are increasingly using AI based algorithms to deny claims, and it's causing a

Ashish Jha: 00:05:16

lot of frustration in the marketplace. Look, there are times when it would be reasonable to deny certain claims. Some services may be completely without any evidence. Some are extraordinarily expensive. That's not what is happening here, when you have Medicare Advantage Plans denying one in six claims that represents a very serious problem, and essentially, what they're doing is forcing doctors to try to peel knowing that they'll end up reversing a bunch, but they also know that sometimes doctors will just give up and not bother doing this. The claims, as I said, 17% overall, 21% among outpatient claims, 17% inpatient claims. So really, it's about 17 to 20% outpatient inpatient everywhere. Doesn't seem to differ that much between urban and rural areas, a little bit, not so much by different type of health insurance plans as well. So that's your study of the week, and I thought it was really important to cover this because this is something that I think needs substantial reform. Lot of physicians are feeling super frustrated on this issue, and now we have some numbers that actually tell us how often these claims get denied and what happens to them afterwards. Majority of them end up getting overturned over time. So that is your study of the week. Medicare Advantage denies 17% of initial claims from the June 2025, issue of Health Affairs. I

Ashish Jha: 00:06:36

You all right, and now for the one question of the week, and we have a very special guest, and we are recording this in the brown DC office in the heart of the nation's capital, and I'm here with Dr Sweta Chakraborty, who is a behavioral scientist who spends a lot of time thinking about risk communication.

Sweta Chakraborty: 00:07:01

Thank you so much for being here. Lovely to be here. Thank you for having me. Yeah, all right,

Ashish Jha: 00:07:05

so my question for you, I'm gonna do a little preamble, because I'm gonna try to explain the struggle that I have, that so many people in public health have, which is about, how do we communicate risk right? We know bacon's bad for you, but going around telling people to stop eating bacon. I don't know. I personally love bacon, so I'm not gonna make that a case. But at the same time, like there are things that are really bad for you that we do recommend people not do, and I feel like we come across as nannies who are like trying to help people how to live their lives. We are not good at explaining risk, communicating risk numbers that we throw out, like you have a one in 100 chance or a one in 1000 chance. None of that seems to land with people, because people don't understand what those numbers mean. I don't know what those numbers mean exactly. I mean. I understand it intellectually, but I don't

Sweta Chakraborty: 00:07:52

know how to feel about it. So you can imagine what everyone's going through. Yeah. So how do you

Ashish Jha: 00:07:56

think we in public health should do risk communication better. What are elements of good risk communication that you would advise me, other public health communicators to incorporate when talking to the public about things that are risky?

Sweta Chakraborty: 00:08:14

There is a gold standard for risk communication, which is empirically founded. There's a science behind how to communicate science. There's a science behind communicating data and numbers and evidence, and guess what? It doesn't involve actually saying the numbers or the data or the evidence. We know from behavioral science that the best way to actually drive behavioral change is through communication, but it's through understanding how audiences process risk and how they process based on the different what we call cognitive triggers that influence that perception of risk. And there's so many of these that have been empirically founded for decades. And this really comes from psychology, and it's been established for over 50 years now, at this point, from the first cognitive psychologist that began to try and understand the phenomenon of human behavior and how to communicate in a way that aligns behavior to what we know, to what we know, how we want people to act

Ashish Jha: 00:09:12

great. So give me an example, like if you were trying to explain to people about the risk of bird flu becoming a pandemic, we don't know what that number is, that likelihood, but of course, if it happened, it'd be potentially quite catastrophic, like, what are elements you might incorporate into that conversation? Or how would you go about using the empirical basis to communicate a risk like that, or a risk about bacon, or a risk about drinking alcohol or whatever you want to want. And that's

Sweta Chakraborty: 00:09:39

that's the key right is understanding what is the risk and they're all different. So something like a pandemic, and I started my studies in this, and my research in this looking at health outcomes when it comes to acute disease states as well as chronic states as well as emerging and persistent infectious diseases, and they're all different. So we have to first understand what is the perception of that particular risk. So when it comes to pandemics, people actually don't perceive high risk, especially when there isn't a pandemic outbreak. We are complacent by nature, it is invisible, and when something's invisible, it's not at the forefront of our minds, and we are not going to be no matter how much public health officials are asking us to act accordingly. We're not going to do it because there's other risks that take precedence right now, something like alcohol that is much more in your face. There's much more so not so much reporting anymore, because it's such a familiar risk. We're so used to it. It's, there's, you know, crashes happening related to drunk drivers on the regular basis, so it just doesn't get reported. But that's a significant risk, and we can actually capitalize on different stories to be able to make that risk relevant and tangible and not allow for complacency. That same approach has to happen for pandemics. We have to when there isn't a pandemic. We know that we're in the life cycle of an of a pandemic inevitably emerging. We have to use that time to make the risk of a pandemic in terms of perception of risk, we have to bring it to the forefront of people's attention. That's what moves behavior. Got

Ashish Jha: 00:11:07

it so last question like one of the things that people often bring up, so raw milk has been in the news a lot because our health secretary has been promoting raw milk. Raw milk is risky. It's not the riskiest thing in the world. There are other things that are riskier. How do you like if you wanted to talk about raw milk instead of saying it's terrible, don't ever drink it, or it's fine, those are the two messages that seem to come out. How do you help somebody make a decision about raw milk that says it's probably risky, it's probably not worth doing. But if you think about all the risks you take, it's probably not the riskiest thing in the world that you could be doing. Like, help me, because that's where I think I struggle. It's like, it's risky, but I also don't want to be, like, super dogmatic about it's awful. Don't ever do it. Yeah,

Sweta Chakraborty: 00:11:56

so that's one of those. How do you communicate uncertainty, and then how do you come across as somebody who's saying it's okay, but and then you're not trusted once you once you back off. And this is where, and this is a last and probably the most important point of communication is that we need trusted communicators. We need to take the time to identify who is the audience we're communicating to. Are they inaccurately perceiving risk around raw milk. Who do they trust? Who are the mommy influencers, for example, in this case, that they trust? And then how do we actually build relationships with them, or create our own version of that type of influencer that could be trusted, that could really put out a message that resonates with that audience? So it doesn't come down to those the stats and those exact details, right? It comes down to who is communicating. Yes, and so that is what science communities haven't gotten right for decades. We as scientists, think we know best, and we communicate the best, and that's a hard pill to swallow. I'm proud to be a scientist. I know and what you do, you are the best at what you do, and you should be the ultimate, ultimate communicator. But actually the takeaway from behavioral science is understanding that there is not necessarily one voice that speaks to all so taking the time to identify the audience, who they trust, partnering with those communicators and then putting the message out that way and watch the behavioral change.

Ashish Jha: 00:13:16

I love that. Okay. So thank you very much. Sweta, that was awesome. So the principles I take away is who communicates matters and how much they are trusted is really important. Taking things that are invisible and bringing them to the forefront, making them visible is really, really important. And I really like the fact that you started here, that there is entire, an entire, kind of empirical basis for this work, that we don't have to kind of wing it, that there is a science behind communication that's that's very important. You know, I will tell you that I agree with you. I don't think we spend enough time thinking about who is actually doing the communicating. Identifying the right trusted voice, is really important. Thank you so much for joining us.

Sweta Chakraborty: 00:13:55

This was really great. My pleasure. Thank you.

Ashish Jha: 00:14:02

Okay, so there you have it, another episode of a moment in health where we talked about one data point, 62% of people living in Miami, Dade County, are on either Medicaid or on an ACA plan. Particularly important right now when Congress thinks about making cuts to those plans that will kick a bunch of people off of those health insurance programs. We talked about one study, the study in Health Affairs, that showed that 17% of Medicare Advantage claims are denied. One in six. That's a lot of claims. A lot of times. Doctors are ordering things, referring patients that are getting blocked by the Medicare Advantage plans. A majority of them do end up getting overturned, but boy, it creates a lot of stickiness in the system, a lot of frustrations for physicians and patients, and it certainly doesn't seem particularly rational the way it is. And then, last but not least, in my trip to DC, I had a chance to sit down with Dr Sweta Chakraborty and. She is a behavioral scientist, somebody who thinks a lot about risk communication. I asked her questions about, How do we do risk communication better? She reminded us there is actually a pretty good science behind this that sometimes in public health, when we're communicating about risk we don't think about the fact that there are other risks that people face. And so we have to understand that the risks that we're talking about may not be the greatest risk that they face, and that sometimes certain risks that are very familiar can get downplayed. She brought up alcohol. People have a lot of encounter with alcohol, and therefore the familiarity makes it feel like not so risky. And last, but certainly not least, she brought up the importance of trusted voices, that even though in public health, we think, okay, we're going to be the trusted voice, the truth is, there are a lot of other people. And this is something we've come up with before, and we talked about this with Jennifer Nuzzo not that

Ashish Jha: 00:15:49

long ago. There are a lot of people who are more trusted than scientists, more trusted than public health experts, more trusted than even physicians and nurses, and engaging those folks to deliver the most important messages is going to be very, very important if we want to rebuild trust and communicate risk more effectively. Thanks a lot for joining us. We will be back again next week for another moment in health where we'll talk about a data point, we'll discuss the study and we will answer a question. Have a great week, everybody.

Unknown: 00:16:22

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