Image courtesy Kaiser Health News.

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<p>Or maybe not.

Nonetheless, advocates on all sides of the debate are sure going to try to convince you.

By Rose Hoban

It started with a tweet.

Many people who follow the General Assembly know to follow the Twitter hashtag #NCGA for news of what’s happening at the legislature.

Sometime in the summer of 2014, a new user popped up in that Twitter stream, an account called “TruthInMedicaid,” just as members of the House and Senate were arguing over the future of North Carolina’s Medicaid program.

The N.C. Medicaid Choice website and twitter feed is sponsored by managed care companies. Image courtesy twitter.

The anti-managed care TruthInMedicaid account was quickly followed by Twitter accounts touting the benefits of Medicaid managed care organizations and the need to change the state’s system of care for almost 1.8 million beneficiaries.

Blogs, websites, emails, more tweets and op-eds have followed, ebbing and flowing along with activity in the legislature. All this online activity has one purpose, it seems: to influence the debate over the future of Medicaid.

But does it matter?

For more than two years, ever since the conclusion of the Medicaid Reform Advisory Group process, Republicans in the House and Senate have been locked in a philosophical battle of wills about the reform of Medicaid in North Carolina.

House members – in particular, Appropriations Committee Chair Nelson Dollar (R-Cary) – have been supporting a model of reform that would emphasize in-state organizations that take on financial risk for running the program and reducing costs. That stance has evolved recently with a proposal backed by the state’s hospital and medical associations for “provider-led entities” that would assume most, if not all, of the financial risk, while leaving the state managing Medicaid overall.

On the other side of the legislative building, members of the Senate, led by Sen. Ralph Hise (R-Spruce Pine), the Health Care Committee chair, with the support of Senate leader Phil Berger (R-Eden), have been pushing for the introduction of Medicaid managed care companies to come into North Carolina and run the state’s Medicaid program.

Their argument is that they’re looking for budget “predictability,” giving the companies a set amount of money each year. Those companies would be obligated to run the program and stay within budget.

The companies also take a slice of money off the top as profit.

Who’s behind it?

On their webpage, TruthInMedicaid features stories about Medicaid managed care shortcomings around the country – in particular, emerging issues in Florida and the benefits of accountable care organizations.

The anti-managed care twitter feed Medicaid Choice NC appeared after the pro-managed care website was launched. Image courtesy twitter.

Want to find out who’s behind the TruthInMedicaidReform account? No dice.

On the website, there’s silence around who’s behind the effort: no “About” page, nothing. The web registration has been anonymized via a company in Scottsdale, Ariz. All the lobbyists who would be representing one of the “usual suspects” have denied any involvement.

After a year, the Twitter account only has 131 followers, mostly reporters, lobbyists and legislators. The audience isn’t large, but it’s influential.

Since the appearance of TruthInMedicaid, more websites purporting to deliver the “truth” about Medicaid in North Carolina have proliferated. Now there’s @NCMedicaidChoice, a Twitter feed created by Medicaid managed care companies Aetna, Amerigroup, AmeriHealth Caritas, UnitedHealth Group and WellCare, which would stand to benefit from a plan that emphasizes the use of corporate managed care.

Using an almost identical logo and name is @MedicaidChoiceNC, another anonymous account, which on its website proclaims: “Who would you rather have providing your healthcare: a team of health providers or an insurance company bureaucrat?”  Again, everyone denies involvement in that site.

New to the mix is the Carolina Partnership for Reform, a blog and Twitter feed run by longtime Republican operative Robert (Bob) Harris and Republican operative and sometimes-candidate Jeff Hyde. Their writings are free market oriented, recently touting the excellence of Medicaid managed care, among other topics.

[pullquote_right]Like this story? Want more? Support us today!![/pullquote_right]Lately, Carter Wrenn and Gary Pearce, the odd couple of North Carolina politics, have also dipped their toes into the Medicaid managed care debate.

Meanwhile, the John Locke Foundation has been praising Medicaid managed care for several years, supporting the efforts of Florida’s managed care plan that scaled up statewide in the past year.

All the while, the N.C. Justice Center has been pushing for Medicaid expansion.

The question is: Does any of it matter? Or is all of this online activity simply speaking to people who already have formed their opinions?

Time to change?

Lobbyist and social media consultant Brian Lewis said running a social media campaign has become a necessary part of doing any advocacy, even if the audience is practically nonexistent.

“It’s like lawn signs for candidates,” Lewis said. “No one ever won a campaign because they had lawn signs. But if you don’t have them, it looks like you don’t care about the campaign.”

Lewis said that it’s the same now with social media: If you want to get your point across, you have to have the Twitter feed, the Facebook page, the blog and other aspects of online presence to show you’re engaged.

“Otherwise, it looks like you’re disorganized and really don’t care,” he said.

What Lewis didn’t say is that he believes all that social media could sway opinion.

Image courtesy Kaiser Health News.

Turns out the literature on how easily people change their minds is mixed, at best.

One reason is that people are subject to “confirmation bias,” a psychological phenomenon wherein people discount data that contradict their preconceived beliefs and put more weight on the data that confirm what they already believe.

Then when you can cherry pick data to back up your assertions, the confirmation is complete.

Duke University behavioral economist Dan Ariely noted that the way an argument is framed can make a difference for someone who’s looking to make a decision on an issue.

“Words are very powerful because they get us to make analogies from this context to other contexts and they help us to borrow moral considerations from other things,” he said.

The two sides of the Medicaid issue frame their arguments differently: One side talks about a “homegrown” Medicaid that’s a “working” system, versus “rushing into” a “corporate,” “for-profit” system. The other side talks about “choice” and “reliability” that “make sense,” versus one that’s less modern and doesn’t provide “competition.”

“Those words do matter, and they also matter in the question of how we think about health care and what people have the right to get,” said Ariely, who has done extensive research on how people’s perceptions can be influenced by marketing tricks.

Those marketing tricks could include the language used in talking about different forms of Medicaid. But is anyone being swayed from one side to the other?

“Depends how sure people are,” Ariely said. “The more sure they are the more difficult it is to change peoples’ mind.”

And that seems to be the case at the legislature. The debate about how to proceed on reforming Medicaid has been waging for more than two years now, with little movement by lawmakers from one side to another. The plans currently being proposed by the House and the Senate look pretty familiar to people who’ve been watching the debate play out for a while.

The difference is that this year Berger has signaled that the legislature will not be going home until the Medicaid question is settled.

So unless someone changes their mind, it could be a long wait for adjournment.

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