Two-thirds of Americans support Medicare-for-all (#5 of 6)

Celinda Lake’s “research” for the Herndon Alliance
By Kip Sullivan, JD

One key player was Roger Hickey of the Campaign for America’s Future [CAF]. Hickey took … Jacob Hacker’s idea for “a new public insurance pool modeled after Medicare” and went around to the community of single-payer advocates, making the case that this limited “public option” was the best they could hope for. … And then Hickey went to all the presidential candidates, acknowledging that politically, they couldn’t support single-payer, but that the “public option” would attract a real progressive constituency…

The rest is history. Following Edwards’ lead, Barack Obama and Hillary Clinton picked up on the public option compromise.

So what we have is Jacob Hacker’s policy idea, but largely Hickey and Health Care for America Now’s political strategy. It was a real high-wire act – to convince the single-payer advocates, who were the only engaged health care constituency on the left, that they could live with the public option as a kind of stealth single-payer, thus transferring their energy and enthusiasm to this alternative.

That is how Mark Schmidt summed up the strategy of the “public option” movement in a short piece for the American Prospect last August. Schmidt’s analysis, rarely seen anywhere else in the media, was correct. I would have added two details to Schmidt’s article.

First, Hickey and other “option” advocates attempted to justify their abandonment of single-payer by claiming most Americans opposed it. This “people don’t like it” version of the “political feasibility” argument against single-payer was new. Prior to the emergence of the “public option” movement, those who refused to support single-payer on “political feasibility” grounds claimed the insurance industry was too powerful to beat. They did not assert that Americans were opposed to single-payer, no doubt because they knew such a statement was demonstrably false.

The other weakness in Schmidt’s analysis was his failure to mention the Herndon Alliance, “the most influential group in the health care arena the public has never heard of,” as Carrie Budoff Brown put it in an article for Politico. It was the Herndon Alliance (of which CAF is a member) which manufactured the “evidence” that Hickey and other “option” advocates cited when they were making the rounds to Democratic candidates and progressive groups to urge them not to support single-payer and to support the “option” instead. It was the evidence they needed to state, with a straight face, “Americans are scared to death of single-payer,” to quote CAF’s Bernie Horn once more. (For information on the origins of the Herndon Alliance and Lake’s “research” for the Alliance, see my paper here.)

The Herndon Alliance hired pollster Celinda Lake to produce the evidence they were looking for. Lake delivered the goods. Over the course of 2006 and 2007, she conducted focus group sessions and carried out at least two polls. By the fall of 2007, Lake turned over to the Herndon Alliance the results they had asked for. Lake “found” that “people” don’t like single-payer. Instead they like something Lake called “guaranteed affordable choice,” a label that would be changed two years later to “the public option.”

Roger Hickey, for one, wasted no time putting Lake’s “research” to use. In November 2007, at an event sponsored by New Jersey Citizen Action, a chapter of USAction (a member of the Herndon Alliance and the soon-to-be-formed Health Care for America Now), he made this statement:

[T]he hard reality, from the point of view of all of us who understand the efficiency and simplicity of a single-payer system, is that our pollsters unanimously tell us that large numbers of Americans are not willing to give up the good private insurance they now have in order to be put into one big health plan run by the government. Pollster Celinda Lake looked at public backing for a single-payer plan – and then compared it with an approach that offers a choice between highly regulated private insurance and a public plan like Medicare. This alternative, called “guaranteed choice,” wins 64 percent support to 22 percent for single-payer.

I won’t bother asking why Hickey and the Herndon Alliance didn’t rely on the citizen jury and polling data I reviewed previously (in Part 2 and Part 3) that show two-thirds of Americans support a Medicare-for-all system. But it is worth raising this question: Why didn’t Hickey and the Herndon Alliance cite the polls that Jacob Hacker relied on? Why commission Lake to do more “research” when Hacker was already convinced he had the evidence necessary to undermine the single-payer movement? By November 2007, when Hickey spoke to New Jersey Citizen Action, Hacker had published several papers examining polling data (including the 2006 and 2007 papers I reviewed in Part 4.)

I suspect the reason is that the Herndon Alliance didn’t find Hacker’s papers as compelling as Hacker did. They felt they needed research that produced more than the equivalent of a Rorschach blot. They needed research that focused specifically on single-payer and the public-private-plan choice proposal.

Lake’s “research”: “Mysterious forces” and “discount consumerism” are “values”

We had people in our focus groups saying, “Well, this is Canadian-style health care,” and we found that the answer was, “No, no. This is American health care.” And people would go, particularly those proper patriots who just love America, “Oh, well great. Then it’s got to be better. This is much superior.” Now the irony is … that American-style health care does not include Medicare for all or a system-wide social security, both of which are frankly frighteningly flawed programs in the voters’ minds. (page 44)

These words were spoken by pollster Celinda Lake at a September 29, 2006 conference sponsored by the Herndon Alliance, just two weeks before Slate published the article by Jacob Hacker that I examined in Part 4. But whereas Hacker was misinterpreting polls taken by polling firms over which he had no control, Lake was accurately reporting on the “first round” of her own “research” over which she had complete control. Her “research” was based on discussions with eight focus groups, each with eight to ten people, which her firm convened in Columbus, Ohio and Atlanta, Georgia in July and August of 2006 (see footnote 2 in Celinda Lake et al., “Health care in the 2008 election: Engaging the voters,” Health Affairs 2008; 27:693-698).

But Lake shared Hacker’s agenda: to demonstrate that Americans like the existing health insurance system and fear a Medicare-for-all system. Hence her celebration of “patriots” and their disdain for “Canadian-style health care.” Hence her trashing of Medicare as a “frighteningly flawed program.” Hence her recommendation that universal coverage advocates assiduously avoid the phrase “Medicare for all” in favor of “choice of public and private plan” (see page 81 of Lake’s presentation.)

At another Herndon Alliance conference held in November 2007, convened to hear Lake’s “findings” from ten more focus groups that were held in Denver, Colorado, Concord and San Diego, California, Columbus, Ohio, and Orlando, Florida during June and July of 2007, Lake continued her assault on the idea that Americans would support a single-payer system. Again she claimed the people in her Atlanta and Columbus focus groups couldn’t stand the thought of Medicare-for-all or what she insisted on calling “Canadian-style health care”:

[W]e found that people want an American solution. My favorite epiphany is in the first round of work was everybody [says], “It’s going to be Canadian style health care.” Americans don’t want Canadian style-health care. They want American health care. (page 17)

To make sure their audience got this point, the Herndon Alliance entitled this conference, “American Values, American Solutions.”

So what did Lake discover from her 2007 focus groups that “people” did like? Amazingly, they liked exactly what Hacker had recommended a year earlier in his Slate article and six years earlier in a paper written for the Robert Wood Johnson Foundation. “People” liked having a choice between private health insurance and a public program.

As Lake put it:

People don’t want to go to a government health care system. But they do like the idea of the government as the enforcer, the watchdog, the setter of standards, as you will remember in the first research. … [I]n the second round research we found … that they were fine with government offering a public plan. In fact they thought there was a lot of merit to having a choice between a private plan and a public plan. (page 15)

Lake had presented to her 2007 focus groups what she called a “guaranteed affordable choice” proposal – a proposal that would give all Americans a choice between private insurance and a publicly run insurance program. Did she also present to them an accurate description of single-payer? Almost certainly not, but we’ll never know for sure. Unlike the groups that convened the citizen juries I described in Part 2, Lake refuses to release the methodology she used in questioning her focus groups.

Lake has, however, released an extensive description of her methods for selecting her focus groups. This methodology is just plain bizarre. Lake says she or the Herndon Alliance (it is not clear which) hired a Fortune 500 consulting firm called American Environics to compile a list of 117 American “core values that shape … views on health care.” The list of “values” included one pop-psychology phrase after another that might make sense to the marketing department of L’Oreal (one of the firms American Environics boasts it consults with) but are laughably irrelevant to the US health care reform debate.

Among the 117 “values” were “brand apathy,” “discount consumerism,” “upscale consumerism,” “more power for big business,” “meaningful moments,” “mysterious forces,” “traditional gender identity,” and “sexual permissiveness.” “Discount consumerism” was defined, for example, as “preferring to buy discount or private label brands, often from wholesalers.” “Meaningful moments” was described as, “The sense of impermanence that accompanies momentary connections with others does not diminish the value of the moment.” (For a complete listing of these 117 “values,” starting with “acceptance of violence” and ending with “xenophobia” – defined as “too much immigration threatens the purity of the country” – see the appendix to the American Environics’ report here.)

On the basis of these “values,” Lake somehow divided Americans into eight groups and gave them names like “Proper Patriots” and “Marginalized Middle-Agers.” Here is how Lake explained this process at the November 2, 2007 Herndon Alliance conference:

One of the things that we also did in the Herndon process was to identify key constituencies of opportunity at the values level. (page 20)

She then selected her focus groups to reflect these groupings. Notice how different this method of selecting focus group participants is from the method used by the organizers of the citizen juries I discussed in Part 2. The organizers of those events sought to select jurors who represented a cross-section of America. It seems highly unlikely that a “methodology” that involved quizzing prospective focus group participants about “meaningful moments” and “brand apathy” would result in focus groups that represented a random sample of the American adult population.

Celinda Lake’s poll

The statements Lake made at Herndon Alliance meetings about how “people” feel about Medicare and “guaranteed affordable choice” were based on her focus group “research.” The statistic Hickey quoted – “voters” choose “guaranteed affordable choice” over single-payer by a margin of 64 percent to 22 percent – was produced by a poll Lake’s firm conducted in September 2007. (See page 23 of Lake’s presentation.)

The poll asked this question:

Which of the following two approaches to providing health care coverage do you prefer?

• An approach that would guarantee affordable health insurance coverage for every American with a choice of private or public plans that cover all necessary medical services, paid for by employers and individuals on a sliding scale; or

• a single government-financed health insurance plan for all Americans financed by tax dollars that would pay private health care providers for a comprehensive set of medical services.
(See page 18 of Lake’s presentation.)

There are four choices involving words or omission of facts that introduced bias into this question. But before we examine those biases, I want to call the reader’s attention to how badly Hickey misrepresented Lake’s poll. Hickey said “our pollsters unanimously tell us that large numbers of Americans are not willing to give up the good private insurance they now have in order to be put into one big health plan run by the government.” That’s not what Lake’s poll said, even taking it at face value. Her poll asked respondents, “Which of two approaches … do you prefer”? A question that asks about preferences cannot be interpreted as evidence of what Americans “are not willing” to do. If I ask you if you prefer tea or coffee, and you say coffee, I can’t claim you “are not willing” to drink tea. I can only claim you prefer coffee over tea.

Here are four biases Lake introduced into her poll:

(1) The definition of single-payer includes the words “government” and “tax” while the definition of “guaranteed affordable choice” does not.

(2) The “tax” in the definition of single-payer is not described as “progressive” or “sliding scale,” but financing is described as “sliding scale” in the “guaranteed affordable choice” definition.

(3) The “guaranteed affordable choice” option is presented as if it were possible to “guarantee … health insurance for every American” without taxes, that is, without compulsory payments of some sort. The “guaranteed affordable choice” option is described as “paid for by employers and individuals.” That has a much more voluntary ring to it than “tax.” But in fact no system of universal coverage can be achieved without compulsory payments of some sort by the populace. If Lake and her colleagues in the “option” movement are actually claiming the “guaranteed affordable choice” proposal will establish universal health insurance, then they cannot ethically describe single-payer’s funding source as “taxes” and not describe the payments by “employers and individuals” under the “guaranteed affordable choice” proposal as taxes.

(4) Perhaps most importantly, Lake’s poll failed to explain the real consequences of the “guaranteed affordable choice” proposal. These include the fact that Americans will not regain their freedom to choose their own doctor under “guaranteed affordable choice” or any other proposal that leaves the current health insurance industry in place. Another unmentioned fact is that “guaranteed affordable choice” cannot cut costs, which means taxes and/or compulsory payments will have to be higher and/or that coverage will be worse under the “guaranteed affordable choice” proposal.

Even if Lake’s poll had asked about opposition to single-payer and “guaranteed affordable choice” rather than preferences between them, the poll was too biased to produce reliable results. Like the amorphous polls Hacker relied on, and like Lake’s focus group “research,” Lake’s poll is no match for the rigorous research that shows that two-thirds of Americans support single-payer.

Invoking the ends to justify the means

There was a time when Celinda Lake was more interested in the truth than in pleasing her patrons. In the early 1990s, Lake conducted polls and focus groups which led her to conclude that Medicare is a very popular program and that large majorities of Americans support a Medicare-for-all or single-payer system. In 1992, before she went to work for the Clinton administration and long before she went to work for the Herndon Alliance, Lake published an article in the Yale Law and Policy Review in which she made these statements:

Americans believe that the market system has failed completely in the medical arena. Their disillusionment with the private health insurance industry leads them to believe that even a governmental bureaucracy would prove more efficient and provide less costly health care. In one western state, two-thirds of voters agree that health costs have surged so high that only a government health-care system can bring them under control. Almost two-thirds (62 percent) reject the idea that private industry will keep medical costs cheaper than would a government-run system with cost controls…. Sixty-nine percent support a universal government-paid system similar to the Canadian system…. Voters strongly support a national health-care system that mirrors or expands Medicare and see no reason why such a system cannot be established. National health-care reformers would do well to talk in terms of expanding Medicare. Just mentioning the words “Medicare-like system” increases voters’ support for any described system by about 10 percent. Framing the issue this way increases support across all age groups…. (Celinda Lake, “Health care: The issue of the nineties,” Yale Law and Policy Review 1992;10(2):211-224).

In 1993, Jeff Cohen and Norman Solomon quoted Lake saying that the more people know about single-payer the more they like it. Cohen and Solomon wrote:

After conducting extensive focus groups on health care, pollster Celinda Lake discovered that the more people are told about the Canadian system, “the higher the support goes.”

In these excerpts, Lake sounds just like me and every other single-payer advocate in America – and very unlike the Celinda Lake of today. Her statements that two-thirds of Americans support single-payer, that likening a proposed reform to Medicare “increases voters’ support … by about 10 percent,” and that support for single-payer rises as people learn more about it could have been made by any knowledgeable single-payer advocate at any time over the last two decades.

So what explains the difference in Celinda Lake’s findings and recommendations in 1992 and 1993 and her “findings” and recommendations post-2005? Did American support for single-payer really head south during those years? Did support really fall from the 69-percent level Lake reported in 1992 to the 22 percent level that Lake “found” in 2007 and which Roger Hickey so enthusiastically reported to New Jersey Citizen Action that year? The citizen jury experiments and the survey research I reported in Parts 2 and 3 of this series, as well as a large body of other relevant evidence I have not reviewed (such as the undiminished popularity of the Medicare program despite constant attacks on Medicare by the right) demonstrates that public support for single-payer did not fall over those years.

What changed was Celinda Lake’s attitude about single-payer. Apparently, Lake came to believe what Jacob Hacker believes: that politics must be elevated above policy; that means may be justified by the ends; that corrupt “research” may be pawned off as rigorous research if the cause is good enough; and that the single-payer campaign may be sabotaged for the higher good as defined by the leaders of the “public option” movement. Lake apparently came to believe, to quote an infamous memo, that “the facts” were going to have to be “fixed around the policy” and that it was her job to create the “facts.”

Stay tuned for the conclusion, Part 6: “Should polls matter?”