Part 6: Two-thirds of Americans support Medicare-for-all

Should polls matter?
By Kip Sullivan, JD

I am here today to say I think the employer-based health care system is dead. I think we need to find a system that’s not built on the back of the government. I am here to also say I don’t think we need to import Canada or any other system. We are going to build an American system because we are Americans and we don’t like any other system. So we are going to build our own….. This is now simply a question of leadership and political will. It is not a question of policy. No more policy conferences. (See pages 15-16 of the transcript of the conference proceedings.)

Those were the remarks of Andy Stern, president of the Service Employees International Union, a member of the Herndon Alliance and Health Care for America Now (HCAN). Stern made those comments at a June 16, 2006 conference sponsored by the Brookings Institution and the New America Foundation.

It is interesting to consider how similar Stern’s remarks are to those of other “option” movement leaders I have quoted in this six-part series. Like Celinda Lake, Jacob Hacker, Roger Hickey (Campaign for America’s Future) and Bernie Horne (also CAF), Stern has no qualms about promoting the insidious claim that single-payer cannot be enacted in America because “Americans” don’t want it. Like Hacker, Stern preaches opportunism dressed up as political wisdom (he calls for more “political will” and no more stinkin’ “policy conferences”).

Fixing the “facts” around the policy

But what I find most intriguing about Stern’s anti-single-payer remarks is the date they were made. They were made on June 16, 2006, which was after the Herndon Alliance hired Celinda Lake to produce “research” showing Americans don’t want a Medicare-for-all system, but several weeks before Lake convened her first focus groups and three months before Lake would reveal her “results” at a Herndon Alliance conference. We know Lake had to have been hired by the Herndon Alliance no later than May 2006 because that was the month she and American Environics published the goofy Road Map to a Health Justice Majority (the one that listed 117 “values” like “brand apathy”), which, according to Lake, gave her the information she needed to select the right mix of “Proper Patriots” and “Marginalized Middle-Agers” for her focus groups. But we also know Lake did not host the first Herndon Alliance focus groups until July 2006.

Thus, in June 2006, Stern had no data – no focus group research, no poll results – to support his remarks. In fact, as we have seen in Parts 2 and 3 of this series, the best research showed that Stern had it backwards, that for at least the previous two decades two-thirds of Americans supported a Medicare-for-all system. But as one of the movers and shakers within the Herndon Alliance, Stern had to have known Celinda Lake would shortly deliver results from her focus group “research” designed to lend credence to his comments. But unlike Roger Hickey, Richard Kirsch, and other leaders of the Herndon Alliance who refrained from claiming single-payer was “un-American” until they had Lake’s “findings” in hand, Stern could not contain himself. Stern was so eager to undermine the single-payer movement that he announced Lake’s “facts” before Lake “documented” them.

It appears Stern also knew that Lake would “find” that Americans liked the “public option.” At the June 2006 conference, Stern blurted out this strange statement: “I think the single payer issue is a stalking horse for I am not sure what because we are going to have a multi-payer system … in America.” (page 20) The statement is strange because the two parts of the sentence don’t connect, and because the statement came out of the blue. If you read the half page of the transcript that precedes this statement, you will see how completely out of context it was. Why did Stern have the “single-payer as stalking horse” metaphor on his mind? Why did he use the metaphor and then fail to explain what single-payer was a “stalking horse” for?

The only explanation that makes sense is that Stern and other Herndon Alliance leaders had decided earlier (probably in 2005) to substitute the “public option” for single-payer; they had already anticipated that conservatives would characterize the “option” as a “stalking horse for single-payer”(that’s in fact precisely what did happen); and Stern, in his eagerness to move the anti-single-payer campaign along, inadvertently opened a window, however briefly, onto this Herndon Alliance secret.

If my hypothesis is correct, the secret that Stern was so tempted to reveal was that the Herndon Alliance had decided by no later than June 2006, and probably much earlier, that it would seek to take single-payer off the table and replace it with the “public option,” and they would hire Celinda Lake to create the “facts” that justified their decision to sabotage the single-payer campaign.

Should polls have been influential with leaders of the “public option” campaign?

Unlike Stern, other representatives of the Herndon Alliance managed to keep their anti-single-payer remarks in check until Celinda Lake published her focus group and survey “research.” From that point on, the company line within the Herndon Alliance and (after the formation of HCAN in July 2008) within HCAN was that “public opinion research” had forced its advocates to abandon single-payer and endorse the “option.”

For example, after announcing in his June 2009 comment that Americans are “scared of single-payer,” Bernie Horn, CAF’s blogger, asked rhetorically, “How do we know this?” His answer:

Over the past two years, progressive groups have conducted an unprecedented amount of public opinion research about universal health care. Usually it’s the conservatives who have all the polling data.

For the sake of discussion, let’s take the “option” campaign leaders at their word and assume they consulted polls first and set policy second. And let’s also assume they honestly overlooked the citizen jury and survey research I reviewed in Parts 2 and 3. Assuming all that, let us now ask: Should people who seek to change society in fundamental ways consult polls before they make decisions about how they will do that? Would the single-payer movement, for example, have been well advised to mimic the Herndon Alliance and conduct its own surveys before deciding to undertake a campaign for single-payer? No!

Why not?

First, people who seek to make social change must have some familiarity with the society within which they hope to make change. If they must consult polls to know how their fellow citizens will react to their efforts, they are probably in the wrong business.

Second, public opinion is malleable, especially on complex issues. To put this another way, the context – the environment – within which people are asked to express an opinion matters, and that context can be changed, for better or worse, by human effort. Treating survey data as evidence of “barriers” to social change, which is how Jacob Hacker and other “option” advocates have treated their cherry-picked polling data, is equivalent to saying public opinion can’t be changed and that solutions to problems must be tailored to fit the allegedly immutable public “values.” In short, giving polls as much deference as they have allegedly been given by “option” campaign leaders can be tantamount to abandoning fundamental reform in favor of more incremental reform, especially if the polls in question were sloppily done or misinterpreted.

The political use of polls

We have already encountered evidence for this conclusion. In the discussion of the 1993 Jefferson Center citizen jury we saw that that jury rejected President Bill Clinton’s Health Security Act at a time when polls were saying a majority of the public supported it. The difference was immense: Only 21 percent of the jury supported Clinton’s bill compared with roughly 60 percent in contemporaneous polls. The polls, limited as they always are in the amount of information they could provide, were woefully inadequate predictors of how Americans would feel about Clinton’s bill once they knew the most important facts about it. This truly American jury went on to endorse Sen. Paul Wellstone’s single-payer legislation by 71 percent. If we gave credence to the polls taken in the fall of 1993 (which is when the Jefferson Center jury met) and knew nothing about the citizen jury, we would have concluded American opinion was considerably more conservative than it was.

A 2009 paper entitled, “The political use of poll results for a privatized health care system in Canada,” confirmed this thesis that polls can serve as the handmaiden of the right wing. The paper reported on the results of an experiment in Montreal in which the investigators first polled a group of people about how to finance universal health insurance in Quebec, and then subjected them to a crude version of the citizen-jury education process and posed the same questions again. (Damien Contandriopoulos and Henriette Bilodeau, Health Policy 2009;90:104-112.) There was an enormous difference between the answers the group gave upon initial polling and after they had been exposed to more information and given an opportunity to talk among themselves. Moreover, the results of the post-quasi-citizen-jury poll were substantially to the left of the first poll results.

The experiment was conducted on behalf of the Clair Commission, a commission established by the province of Quebec in 2000 to recommend changes in its single-payer, universal coverage system. The commission met at the end of a decade of intense debate throughout Canada about whether Canada’s single-payer system would be better off if, among other things, Canada’s universal health insurance system were financed less by taxes (the liberal position) and more by out-of-pocket payments by patients, also known as “user contributions” (the conservative position). The commission convened ten focus groups, with 12 people in each group selected to represent a cross-section of Montreal’s population. The commission initially gave the focus groups only four choices: increase taxes, remove coverage of certain services, create a special fund, or require more patient out-of-pocket payments.

Commission staff made what was apparently a superficial presentation of the issues raised by these options and then, before the groups had a chance to talk among themselves, asked for a vote. The largest vote-getter on this first round was more “user contributions,” something conservative groups in Quebec had been promoting through advertisements and other means. Thirty-four percent voted for this option.

After this vote was taken, some of the participants objected to their limited set of options. According to the authors, the objections were probably motivated by a desire, clearly expressed by some participants, to add a progressive tax (not merely “taxes”) to the option list. In any event, prior to the final vote, “refusal to choose any of the options” was added as a choice but “progressive tax” was not added. After the presentation of more information and a chance for participants to talk and debate, a final vote was taken. A gargantuan 62 percent chose “refuse to choose.” The other four options – the ones the commission staff was seeking the groups’ opinion on – together garnered only 38 percent of the vote. The main loser was “user contributions;” now only 13 percent chose that solution.

For whatever reason, the Montreal “jury,” armed with information and emboldened by the opportunity to compare values and perceptions with one another, rebelled against its handlers and refused to go along with the limited choices they were given.

The authors remarked:

[T]his example shows that it is perfectly possible – and probably even common – that poll results do not reflect the opinions respondents would have provided if they had been given the time or the opportunity to reflect on the issues. (Page 109)

The Montreal experiment reveals the same pattern we have seen in the citizen jury and polling data I reviewed in Parts 2 and 3 of this series: Knowledge about a subject, including the knowledge generated by a debate about it, can produce measures of public opinion that produce results quite different from survey results, especially results generated by uninformative or biased poll questions. And, as was the case with the Montreal “jury,” we have seen that the direction of this opinion shift is away from the status quo and incremental reform and toward fundamental reform.

To recap Parts 2 and 3: We saw that the two citizen juries produced support levels as high as the 70-plus-percent range; that polls which compared single-payer to Medicare or some other existing single-payer system produced support levels in the 60-to-70-percent range; and that polls which provide little information or misinformation tend to produce support levels below 60 percent.

The founders of the “option” campaign did not fall off the turnip truck yesterday. They were well aware of the fact that polls can produce biased and inaccurate results. Nevertheless, they decided to feign great deference to amorphous polls badly interpreted, and to biased polls.

Single payer is the only solution

There is a third reason – one specific to the health care crisis – why consulting polls first and adopting strategy and policy second is a bad idea. And that is that a single-payer system is our only way out of this mess. We must get US health care costs down for both economic and moral reasons. But we must also get costs down for political reasons. Andy Stern can talk all he wants about finding the “political will” to extend coverage to everyone, but until we as a society find the political will to cut health care costs, we won’t find the political will to achieve universal health insurance. The sooner influential people like Stern can find within themselves the political will to support effective cost containment, the sooner Congress will do likewise, and the sooner we will achieve universal coverage.

Single-payer has no peer as a cost-containment method. Every other remedy that has been discussed in this country over the last four decades, and every remedy currently under debate in Congress – more electronic medical records, more report cards on clinics and hospitals, more preventive services, more “disease management,” more “coordination between teams of doctors” as our president is wont to put it, more research comparing the effectiveness of treatments, and the tiny “public option” – every one of those ideas remains, at best, unproven as a cost-containment method, and in some cases will actually raise costs.

To paraphrase Stephen Colbert, the facts have a single-payer bias.

Concluding thoughts on this series

In the spring of 1989, the organizations I was working for (Minnesota Citizens Organized Acting Together and the Health Care Campaign of Minnesota) officially adopted the position that we could not achieve universal health insurance unless we cut the high cost of health insurance in Minnesota and America. I was given the job of organizing a discussion within both organizations about how to achieve real cost containment. Those discussions went on throughout the latter half of 1989, and occurred in a dozen cities throughout Minnesota. In December 1989, both organizations endorsed the single-payer solution.

At no time during those discussions did the people I worked with adopt the Herndon Alliance/HCAN attitude that we had to put our fingers in the wind before we endorsed a solution. We certainly weren’t oblivious to the power of our opponents; in fact, the “political feasibility” question was front and center throughout those discussions. Perhaps it was because polls inquiring about public attitudes toward single-payer were nonexistent, or at least unknown to us, when we began our deliberations. Perhaps it was because members of the discussion groups were not members of or close to the political elite and therefore felt no need to temper their policy recommendations with a desire to make the elite comfortable. Perhaps it was because many of us had devoted a substantial portion of our lives to social change of one form or another and were comfortable with our own judgment, unaided by polls, that a Medicare-for-all system was well within the mainstream of American opinion. For whatever reason, it never once crossed our minds that we ought to hire a pollster to convene focus groups and conduct polls before we made up our minds about what policy to endorse.

Instead, we did what people have done throughout the history of democracy: We reached out to as many individuals and groups as our resources allowed, we did our best to present the facts to each other and to hear each other out, and then we made a decision. We endorsed a single-payer system.

Kip Sullivan is a member of the steering committee of the Minnesota chapter of Physicians for a National Health Program. He is the author of The Health Care Mess: How We Got Into It and How We’ll Get Out of It (AuthorHouse, 2006).