In the second part of this three-part series, I reviewed the evidence indicating the “public option” campaign as well as “option” proponents in Congress refused to adopt criteria that would have guaranteed that the “option” would be large enough to survive competition with the behemoths that dominate America’s highly concentrated insurance industry. This failure to articulate a clear vision of what it would take to ensure large size in the “option” was the first indication that the “option” campaign gave higher priority to an insurance industry bailout than the “option.”

In this part – Part 3 of a three-part series – I review the second type of evidence that indicates the “option” campaign’s highest priority to date has been a bailout for Aetna et al. The evidence I review in this part indicates the “option” campaign never made the “option” a precondition for its support of the Democrats’ “reform” bill, and that even after the Senate passed a bill with no “option” in it the “option” campaign’s leaders (with perhaps the sole and fleeting exceptions of Howard Dean and Moveon.org) continued to support the Senate bill.

No demand that the “option” be included in the final bill

The “option” campaign’s failure to insist that the Democrats’ “option” meet Jacob Hacker’s original criteria (or any other meaningful criteria for that matter), and their willingness to exaggerate the damage the Democrats’ little “option” would do to the insurance industry, were not the only signs that they cared more about the bailout than the “option.” In the final months of 2009 it became clear “option” proponents were not going to make inclusion of an “option” a precondition of their support for the Democrats’ “reform” bills. In short, it became clear “option” leaders couldn’t bring themselves to oppose what even they knew was an unadulterated insurance industry bailout.

This became increasingly obvious in the weeks after September 16 when Senator Max Baucus (D-MT), chair of the Senate Finance Committee, made it official that he would not include an “option” in his bill. “Option” advocates mounted a well-funded publicity campaign throughout the fall and early winter to urge Baucus, Senate Majority Leader Harry Reid and other Senate leaders to include an “option” in the final bill. But at no time – not even after the Senate passed a bill on Christmas Eve without an “option” – did leaders of the “option” campaign tell Democrats they were fed up and would oppose any bill without an “option.”

There were some rare exceptions, notably Howard Dean’s Democracy for America and Moveon.org (both organizations are members of Health Care for America Now). Dean spent a few days in December urging universal coverage advocates to oppose the Senate bill (see, for example, Dean’s December 16 comment on Vermont public radio and his December 17 op-ed in the Washington Post). But despite Dean’s encouragement, HCAN and HCAN member-organizations like the AFL-CIO, SEIU, AFSCME, Planned Parenthood Federation, and ACORN refused to do anything to stop the insurance industry bailout. Many of these organizations severely criticized the bill for not having an “option,” for including a “Cadillac tax,” for restricting the right to an abortion, etc. But none urged a no vote on the ground that the “option” had been stricken from the bill.

In fact, they did the reverse. They urged their followers to support the bill. Hacker led the charge just days after Dr. Dean’s Washington Post op-ed. In a piece published in the Huffington Post on December 20 entitled “Why I still believe in this bill,” Hacker wrote:

Now that the core demand of progressives has been removed from the Senate health care bill – namely, the public health insurance option – should progressives continue to support the effort? …. It would … be tempting for me to side with Howard Dean and other progressive critics who say that health care reform should now be killed. It would be tempting, but it would be wrong.

On December 15, HCAN’s blogger Jason Rosenbaum wrote: “I’d say there’s no question that Health Care for America Now believes the Senate bill doesn’t conform to our principles for reform…” But on December 24, the day the Senate passed its “option”-less bill, HCAN’s campaign director Richard Kirsch hailed the bill as “one big step closer to comprehensive health care reform.” And SEIU President Andy Stern declared, “Make no mistake about it, for working Americans this vote signals progress.”

The “option” campaign’s disinterest in promoting a large “option” (see Part 2), its failure to make even the weak version of the “option” a precondition for its support of the bailout, and its explicit support for the Senate bill are not the only indications the “option” campaign supports a bailout with or without an “option.” The campaign continues to promote slogans designed to drum up support for generic “reform” bills regardless of whether they contain an “option.” For example, Moveon.org has urged the public to “pass Obama’s health care plan” and for the last several weeks HCAN leaders have urged their followers to tell Congress to “get the job done.” On March 9, HCAN sponsored a rally outside a meeting of America’s Health Insurance Plans at which they promoted the false message that the insurance industry is scheming to oppose the bailout HCAN has worked so hard for. As HCAN’s Rosenbaum put it on the HCAN blog, the message of the rally participants was: “We need Congress to listen to us and not the insurance companies. We need to pass real reform now.” Demanding “real reform” is quite different from, “We want a ‘public option’ and we will not support a bailout bill that does not contain an ‘option.’”

Advocates within Congress almost as wishy-washy

Unlike Hacker and HCAN, some “option” advocates within Congress actually threatened to oppose legislation that did not contain the Democrats’ mouse version of the “option.” This happened more often in the House than the Senate. Throughout the spring, summer and fall of 2009, the Congressional Progressive Caucus (which represents 79 Democrats in the House) repeatedly stated that the “option” should be included in the final House bill. They even said on a few occasions their members would vote against a bill that contained no “option.” For example, on June 8 CPC co-chair Representative Raul Grijalva posted a press release on behalf of the CPC that read, “On April 2, the CPC sent a letter to Speaker Nancy Pelosi and Senate Majority Leader Harry Reid stating that a majority of its members would oppose any legislation that did not include a public option.”

Similarly, on September 3, 2009 the CPC sent President Obama a letter in which they rattled their swords once again for what they deemed to be a “robust public option” (which in “optionese” means a tiny “option” blessed by Congress with the meaningless authority to use Medicare’s rates plus 5 percent). “We continue to support the robust public option … and will not vote for a weakened bill on the House Floor or returning from a Conference with the Senate. Any bill that does not provide, at a minimum, a public option built on the Medicare provider system and with reimbursement based on Medicare rates — not negotiated rates — is unacceptable.”

However, when push came to shove, the CPC’s threat turned out to be meaningless bluster. The bill that ultimately passed the House in November did contain a little “option” but not the “robust” version (one authorized to use Medicare rates) the CPC said it had to have. According to Salon, only two CPC members (Representatives Eric Massa, who just resigned from Congress, and Dennis Kucinich) voted against the House bill. And now that President Obama is proposing a compromise bill with no “option” at all in it, the CPC is apparently abandoning even a “less than robust option.” Salon recently reported that Representative Grijalva hinted that he and his CPC colleagues would vote for the insurance industry bailout without the “public option” because, at a March 4 meeting with CPC members, Obama promised to work for an “option” in the future.

Senator Jay Rockefeller appears to be the only “option” proponent within the Senate who stated publicly he would withhold his vote for the “reform” bill if it did not contain an “option.” But Rockefeller soon retracted his threat. Today Rockefeller, like Hacker, argues against adding an “option” to the Democrats’ bailout bill. The failure of HCAN and its member organizations to adopt a similar position may have had something to do with Rockefeller’s about-face.

When did the bailout become the highest priority?

The press release published by HCAN on July 8, 2008, which announced HCAN’s formation, offered this semi-stirring explanation of its mission:

Health Care for America Now offers a bold new vision for health care reform: Americans can keep the private insurance they have, join a new private insurance plan, or choose a public health insurance plan.

Imagine how much less stirring this “vision” would have been if HCAN had announced the position it holds today. The press release would have gone something like this:

HCAN offers a bold new vision: Ten percent of Americans will be given the opportunity to enroll in a public health insurance plan, the other 90 percent will be forced to buy health insurance from the insurance industry, and the taxpayer will be asked to fork over half-a-trillion dollars per decade to the insurance industry. HCAN will not go to the mat for the tiny public program. If necessary, HCAN will jettison the little public program and throw their full support behind an insurance industry bailout. It is more important to HCAN that the insurance industry get millions of new customers and its half-trillion from the taxpayer than it is to enact any form of a public health insurance plan.

Obviously, if HCAN had enunciated this “vision” in July 2008, they would have turned off a sizable chunk of the universal coverage movement. They did not do that. They promised instead a huge public program that would be available to all Americans (they heaped straw in the proverbial wheelbarrow). Jacob Hacker adopted the same tactic.

It was obvious as early as last June when the Democrats introduced their moribund version of the “option” that this tactic had failed. With the failure of the Senate to include even the moribund “option” in the bill it passed on Christmas Eve, with the election of Scott Brown in Massachusetts in January, and with Obama’s refusal to include an “option” in the legislation he announced on February 22, it seems safe to say that what was a moribund “option” has become a dead “option.” However, a naked bailout of the insurance industry – a bailout without even the fig leaf of a little “option” pasted over it – remains a real possibility.

Is this what the “option” campaign wants? Given the campaign’s record, one would have to say it is. It may not always have been so. It is possible that two years ago most of the campaign’s leadership sincerely viewed a bailout as no more important than an “option.” But whatever the campaign leadership’s original motivation might have been, the record shows that at some point, no later than 2009, a bailout became their highest priority and the “option” became a lower priority. The record also indicates that HCAN et al. engaged in deception to conceal this fact.

For the record I would like to stress once again that my objection to the “option” is not that the “option” itself will waste tax dollars, enrich the insurance industry (the country’s most powerful opponent of single-payer legislation), retard the universal coverage movement, and threaten to snuff out the state-level single-payer movement. All those dire consequences flow from the insurance industry bailout – the mandate and the subsidies – not from the little “option,” at least not directly. My primary objection to the “option” is the role it has played in facilitating enactment of the bailout. It has played the role of the straw in the wheelbarrow parable. It has allowed the “option” campaign to turn itself into a campaign for an insurance industry bailout — right under our noses.

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).

It is way past time for “public option” advocates to take a stand either for or against an insurance industry bailout.

Do “option” advocates support the individual mandate in the Democrats’ legislation (a requirement that all uninsured Americans buy health insurance from the bloated insurance industry) and the subsidies that will allegedly make the mandate affordable, even if these provisions are enacted without an “option”? Or do they oppose the mandate and the subsidies if there is no “option” in the final legislation? Does the “robustness” of the “option” have any bearing on their decision, or will any provision with the title “public option” in it suffice to win their support for an insurance industry bailout?

For the last two years, the leaders of the “option” campaign have been extraordinarily vague about what sort of “option” they stand for and whether the “option” is more important to them than an insurance industry bailout. They have refused to adopt minimum criteria that would guarantee that the “option” would be large and they have refused to make the “option,” even the tiny “option” unveiled by congressional Democrats last June, a precondition for their support of the Democrats’ “reform” bills. On the other hand, they have urged their followers to support the Democrats’ bills and, in the case of the Senate bill, they have even urged their followers to support the bill after the “option” was stripped from it.

These tactics – creating a hullabaloo over a vaguely defined “option” but then supporting bailout legislation that contains no “option” – remind me of an old parable about an employee of a factory who, night after night for many years, left the factory pushing a wheelbarrow filled with straw. At the factory gate, the security guard carefully lifted the straw to see what if anything the employee might be stealing and, finding nothing, waved the guy on. On his last day of work, the employee approached the factory gates without his usual wheelbarrow filled with straw and said goodbye to the guard. “What were you stealing all those years?” the guard asked. “I’m sure you were stealing something but I never figured it out.”

“Wheelbarrows!” replied the employee.

Like the wheelbarrow thief who induced the guard to focus on the straw, leaders of the “option” campaign have been promoting a bailout of the health insurance industry – the centerpiece of a plan proposed by the insurance industry — right under the noses of progressives and the media. They have done so by focusing all their rhetoric on the “option.” The public has been inundated by a blizzard of news stories, blog comments and email appeals about the politics of the “option” and how it will work. Will this or that party or politician support it? Will it be open to large employers? Will the co-op version work as well as the more abstract version in the House bill? Will the “option” have the authority to use Medicare’s rates plus 5 percent? Will it attract more than its share of sick enrollees? Should it be in place prior to 2013? And so on.

On the other hand, the “option” campaign has been utterly silent on the most fundamental question one could ask about the bailout: Should Congress enact a requirement that most non-elderly Americans become compulsory customers of the insurance industry and should the taxpayer finance massive subsidies for the insurance industry, with or without an “option”?

Health Care for America Now (HCAN), the most prominent advocate of the “option,” and its allies both inside and outside Congress have been silent on virtually every issue raised by this question: Is it ethical to force Americans to purchase the product of a particular industry? Could the individual mandate backfire on Democrats, especially when the news media starts publishing stories about the IRS enforcing fines against middle-income Americans who don’t or can’t obey the mandate? Will the bailout strengthen the insurance industry and thereby postpone the day America enacts a Medicare-for-all system? Will federal courts decide that the individual mandate, the subsidies and the exchanges pre-empt state single-payer legislation and thereby snuff out the state-level single-payer movement? (See discussion of this issue in my opening statement for a recent live blog and the discussion that followed.) How, if at all, are the answers to any of these questions altered by the enactment of the tiny “option” contained in the House bill?

On these and other critical questions about the bailout – the mandate that Americans buy insurance plus the tax-financed subsidies for the insurance industry in the amount of a half-trillion dollars per decade – the “option” leadership has been silent. Their silence on these issues coupled with (a) their refusal to endorse criteria for the “option” that would guarantee the “option” would be large, (b) their hype about the “option” and (c) their support for the Democrats’ bills even if they contain only a tiny “option” or no “option” at all indicates their true priorities. Like the wheelbarrows in the parable, the “option” leadership’s true priority – the enactment of an insurance industry bailout – has been in plain sight for a long time.

In the remainder of this article I review the evidence indicating the “option” campaign failed to promote to the public or to members of Congress criteria that would have guaranteed the “option” would be large enough not only to survive but to take on the gigantic insurance companies that dominate every market in America today. In the last part of this three-part series, I review evidence indicating the “option” campaign never informed congressional Democrats that an “option” of any sort (large or small) was a precondition for their support of the Democrats’ “reform” legislation.

No minimum criteria for the “option”

The first sign that the “option” campaign would give higher priority to the bailout than the “option” was HCAN’s refusal to adopt any criteria at all for the “option” until long after the Democrats began writing their “reform” bills. Although the bill-writing process began no later than late 2008, HCAN waited until June 2009 to release four vague criteria, and then promptly ignored them.

The bill-writing process began formally in January 2009 in the Senate Finance and Senate Health, Education, Labor, and Pensions (HELP) committees when the new Congress convened, and informally as early as 2008 when Senator Ted Kennedy (chairman of the HELP Committee) convened secret meetings of the “workhorse group.“ (According to the Wall Street Journal, this group began meeting in early 2008. According to the New York Times, it began meeting in the fall of 2008.) The process began in the House in March 2009 when the chairmen of the three committees with jurisdiction over health care reform agreed to write a single House “tri-committee” bill. The bill-writing process was completed by the Senate HELP committee on June 9, 2009 and by the House “tri-committee” on June 19, 2009. On those dates those committees published draft versions of their bills. Nearly identical versions of these bills were formally introduced a few weeks later.

HCAN was well connected in Congress and must have known long before the public did that the HELP Committee and the tri-committee would recommend tiny, ineffective versions of the “option.” (The AFL-CIO, an HCAN steering committee member, was a member of the “workhorse group.”) Nevertheless, HCAN waited until June 12, 2009 to post four vague “option” criteria. Of these, only two related to size, and both of these (“national and available everywhere” and “bargaining clout”) were merely expressions of a desired goal, not descriptions of criteria that had to be met to achieve the goal. Merely expressing the wish that the “option” be “available everywhere,” for example, does nothing to ensure that the “option” is big everywhere.

HCAN could have endorsed Hacker’s original criteria

If HCAN had been serious about promoting a large “option,” it would have endorsed the five criteria proposed by Jacob Hacker, the godfather of the modern “option,” and it would have done so early in the bill-writing process, not after the bills were written.

In papers published in 2001 and 2007 Hacker set forth five criteria that would have guaranteed massive size in the “option:

(1) The program had to be pre-populated (he proposed that states “shift” current Medicaid and SCHIP enrollees and the uninsured into the program prior to the start of operations);

(2) People who enrolled in the public program would get tax-financed subsidies to pay the the public program’s premiums while people who signed up with insurance companies would not;

(3) All non-elderly Americans would be eligible to enroll in the public program;

(4) The public program would have the authority to use Medicare’s reimbursement rates; and

(5) The insurance industry would have to offer the same coverage required of the public program.

According to Hacker as well as the Lewin Group (which published analyses of Hacker’s proposal in 2003 and 2008), a public health insurance company that met these five criteria would be able to insure half the nonelderly population – in 2007, 129 million people – and charge premiums far below those of the insurance industry.

But because the HELP committee and the three House committee chairmen who wrote the House “tri-committee” bill were far more interested in being able to say the “option” would “compete with the insurance companies on a level playing field” than they were in creating a huge “option,” they incorporated only the fifth criterion (insurance companies had to offer comparable coverage) and abandoned the other four. The abandonment of the other four, especially the criteria calling for pre-population and subsidies only for the “option,” resulted in a much weaker and smaller “option” program than the one envisioned by Hacker. The Congressional Budget Office estimated the HELP committee “option” would insure no one and that the House bill would insure only 6 million people. (I have written elsewhere about why even this dismal estimate of the House “option’s” size by the CBO was excessively rosy.)

“Option” proponents cave

June 2009, then, would have been an obvious time for HCAN, Hacker and other “option” proponents to rise up on their hind legs and demand that if Democrats wanted their support for an insurance industry bailout the Democrats would have to take their sick little “option” back to the drawing board and draft an “option” based on Hacker’s original criteria. That didn’t happen. As I have reported earlier, in June 2009 the “option” campaign entered the “switch” phase of what was turning out to be a “bait and switch” campaign. Even though they had to have known by June 2009 that the “option” in the HELP and tri-committee bills were travesties of Hacker’s original proposal, the “option” campaign pretended otherwise. They called the Democrats’ microscopic “options” “robust” and “strong,” and lavished praise on the bills – bills which contained the bailout provisions so coveted by the insurance industry.

Neither HCAN, Hacker nor any other leading individual or group within the “option” campaign made an effort to restore the pre-population and subsidy criteria, and apparently none made any effort to restore the criterion calling for the “option” to be universally available. When Richard Kirsch, HCAN’s campaign director, testified in favor of the House “reform” bill before a subcommittee of the House Energy and Commerce Committee on June 23, 2009, Kirsch knew or should have known that the “option” in that bill did not meet Hacker’s pre-population, subsidy, or universally available criterion. Kirsch, however, made no effort to call his listeners’ attention to that fact. To the contrary, he concealed the small size of the “option” by telling the committee it would be available to everyone.

The only criterion of the four abandoned by Democrats that “option” leaders went to bat for was the one authorizing the “option” to use Medicare’s rates to reimburse clinics and hospitals, and even here they could not bring themselves to fight for Hacker’s original criterion. They pushed not for Medicare’s rates (which are about 20 percent below the rates insurance companies pay), but Medicare’s rates plus 5 percent.

But without Hacker’s first three criteria – the pre-population, subsidy, and available-to-all criteria, which were essential to guaranteeing the “option” would start out large and stay large – the demand that the “option” be given the authority to use Medicare’s rates plus 5 percent was meaningless. Giving a microscopic “option” the authority to use low rates is like giving first-graders the authority to bench press 400 pounds. They can’t do it, and giving them permission to do it doesn’t change that fact. Similarly, an “option” program that represents zero to 6 million people cannot expect clinics and hospitals to agree to be paid below-industry rates (see my discussion of “the chicken and egg” problem here). No dispensation or blessing from Congress is going to change that. What the “option” needed from its supporters was an uncompromising insistence upon large size on the day it opened for business. But the “option” campaign made no effort to fight for the criteria that would guarantee large size. (As “option” proponent Jon Walker recently explained, “option” proponents did, however, adopt the ludicrous label “robust” to distinguish a tiny “option” with the authority to use Medicare rates plus 5 percent from a tiny “option” that does not have that authority. The label was extremely misleading.)

“Option” proponents in Congress equally incompetent

Members of Congress who supported the “option” adopted tactics virtually identical to those of the “option” campaign, and thereby revealed that they too cared more about the bailout than the “option.” They refused to adopt criteria that would guarantee large size in the “option,” they refused to alert the public that the Democrats’ “option” was a mere shadow of Hacker’s original version, and they insisted on calling the Democrats’ scrawny “option” “robust” if it included the Medicare-rates-plus-5-percent provision.

In one of their first letters to the Democratic leadership in the House expressing support for the “option,” the Democratic Congressional Progressive Caucus (CPC) failed to say a word about Hacker’s original criteria. In fact, they made things worse. Two criteria the CPC did endorse in that letter – that subsidies should go to the insurance industry as well as the “option,” and that the “option” pay providers “competitive rates” – nullified two of Hacker’s original criteria (the subsidy and Medicare-rates criteria). The nullification of these criteria would have greatly reduced the power of the “option” vis a vis Hacker’s original version.

Like HCAN, the CPC waited till long after the bill-writing process had begun to develop a list of criteria for the “option.” On June 8, 2009 (four days before HCAN released its four vague “option” criteria), the CPC released the contents of a June 5 letter to Speaker Nancy Pelosi which contained a one-page mish-mash of “principles” they said the “option” had to meet. The mish-mash included, for example, a call for dental coverage and “transparency” in the “option.” On the other hand, it mentioned only one of Hacker’s original principles (the one requiring that all non-elderly Americans be allowed to join the “option”). To make matters worse, the mish-mash included the same two criteria the CPC had adopted earlier which nullified Hacker’s subsidy and Medicare-rate criteria. Unlike HCAN, which never summoned the courage to say it would oppose legislation that did not meet its criteria, the CPC did say in this letter to Pelosi that it would “oppose” the final House bill if it did not include an “option” that met its “principles.” As we shall see in Part 3, this threat turned out to be a bluff.

“Option” proponents in the Senate were even less assertive about spelling out criteria for the “option” and demanding that they be met than the CPC was. A May 29, 2009 letter from 16 Senators to Senators Baucus and Kennedy (chairs, respectively, of the Finance and HELP committees) urging them to include an “option” in their committees’ bills mentioned no criteria. Over the next nine months, nothing changed. On February 16, 2010, Senator Michael Bennet (D-Utah) and three of his colleagues sent a letter to Senator Harry Reid (D-NV) urging him to restore “a strong public option” to the Senate bill. (This letter was subsequently endorsed by two dozen other Senators.) Although this one-page letter used the phrase “public option” 15 times, and although half the time the word “strong” preceded the phrase, the letter made no attempt to define what “strong” meant.

Senator Ron Wyden made an effort late in the 2009 session to make the “option” available to all non-elderly. He received very little support from “option” proponents and his effort failed.

These isolated and, in the case of the CPC, confused efforts by members of Congress to reinvigorate the moribund “option” are further evidence that HCAN and other advocates of the “option” were doing nothing to create pressure on Congress to adopt minimum criteria that would guarantee that the “option” would start out large and stay large.

Compromising on the large “option” had consequences

The small size of the “option” endorsed by Democrats, and the disinterest among “option” proponents both inside and outside Congress in strengthening the “option,” meant the Democrats’ “option” would pose virtually no threat to the insurance industry. It meant the “option” would not be available to the vast majority of Americans (according to the Congressional Budget Office it would be available to about 10 percent of us), and would have very little impact on health care costs in the US.

The small size of the “option” meant, furthermore, that the “option” campaign’s slogans, which arguably had some integrity prior to the introduction of the Democrats’ mouse version of the “option” in June 2009, became false advertising thereafter. No longer could the campaign say they were promoting “quality affordable health care for all.” They were only promoting coverage for some. No longer could they say, “If you like your health insurance you can keep it.” The reality was that the individual mandate plus the tiny “option” meant, “If you don’t like your health insurance, you must keep it (because unless you’re among the 10 percent of Americans with access to the exchange, you won’t have access to the ‘option’”). No longer could the “option” campaign claim the “option” would cut the cost of health care in the US.

As health policy, the “public option” was worthless. But as a political tool it was priceless. As the straw distracted attention from the wheelbarrow, so the “option” distracted attention from the fact that the health care “reform” promoted by the “option” campaign will criminalize the uninsured and transfer hundreds of billions of dollars of public funds to private insurance companies.

Kip Sullivan is a member of the steering committee of the Minnesota chapter of Physicians for a National Health Program.

On July 8, 2008, Health Care for America (HCAN) announced its existence. The press release HCAN published that day described HCAN’s “vision” for health care reform in these words:

Health Care for America Now offers a bold new vision for health care reform: Americans can keep the private insurance they have, join a new private insurance plan, or choose a public health insurance plan.

It is clear today that HCAN’s position is quite different from the “vision” HCAN announced in July 2008. If HCAN had announced on July 8, 2008 the position it promoted during 2009, its announcement would have sounded like this:

HCAN offers a bold new vision: Ten percent of nonelderly Americans will be given the opportunity to enroll in a public health insurance plan, the other 90 percent will be forced to buy health insurance from the insurance industry, and the taxpayer will be asked to fork over half-a-trillion dollars per decade to the insurance industry. HCAN will not go to the mat for the tiny public program. If necessary, HCAN will jettison the little public program and throw their full support behind an insurance industry bailout. It is more important to HCAN that the insurance industry get millions of new customers and its half-trillion from the taxpayer than it is to enact a tiny “option.”

But despite the passage of almost two years, the leadership of HCAN and the “option” campaign has yet to announce to the public that the “option” is dispensable and that HCAN’s highest priority is an insurance industry bailout: tens of millions of compulsory customers plus massive tax-financed subsidies for the industry. To the contrary, the “option” campaign’s leadership continues to employ the tactics it has used from the beginning of the campaign, namely, to generate a great public fuss over the tiny “option” while simultaneously expressing support for bailout legislation that contains an ineffective “option” or no “option” at all.

This behavior reminds me of a parable about a company employee who stole wheelbarrows from the company right under the nose of the company’s security guard. He would leave work every night pushing a wheelbarrow filled with straw. The guard at the factory gate was fooled into thinking the straw hid something and focused all his attention on the straw and never thought to ask about the wheelbarrow. He would carefully lift the straw and look for stolen goods, and, finding none, would wave the employee on.

If we substitute a health insurance industry bailout for the wheelbarrow, and the “option” for the straw, the parable illustrates the strategy of the “option” campaign. By creating a great ruckus over the “option” but all the while supporting bailout legislation (with or without an “option”), the “option” campaign has fooled its followers and the public into thinking its highest priority is the “option” when in fact its highest priority is a bailout.

In this three-part series, I summarize the evidence for this conclusion – that the “option” campaign cares more about the bailout than the “option.” In Part 2 I present the evidence indicating the “option” campaign never adopted criteria that would guarantee the “option” would be large and that it did little or nothing to educate Congress about such criteria. The result of the “option” campaign’s failure to promote such criteria was predictable: Democrats in Congress adopted a very tiny, ineffective “option.” Part 2 also presents evidence indicating “option” proponents within Congress adopted very similar tactics.

Part 3 summarizes the evidence indicating that the “option” campaign’s leaders never made the tiny “option” a precondition for their support of the Democrats’ health care “reform” bills and, to make matters worse, when Democrats in the Senate passed a bill with no “option” in it, the “option” campaign’s leaders continued to support the Senate bill. Part 3 also presents evidence indicating “option” proponents within Congress were almost as wishy-washy about the “option” as the leadership of the “option” campaign was.

Kip Sullivan is a member of the steering committee of the Minnesota chapter of Physicians for a National Health Program.

Dear President Obama:

Health care reform is necessary for the maintenance of a productive society. Modern medicine has advanced so rapidly during 50 years since I began Family Practice that much of what I learned as a medical student and Resident is out of date and technically non existent. The advances are truly amazing and expensive.

I am a member of PNHP (Physicians for a National Health Program). The cost savings of a single system would easily exceed the expense of covering everyone, lower the administrative cost burden for the practicing physician, while decreasing the National tax payer burden. The current proposals fall short due to their complexity.

In 1963, I opened a private Family Practice. I needed a part-time nurse, and a part time receptionist/billing clerk—Today insurance billing, prior approval, varying and often conflicting rules and reports, require at least four full time employees to support one physician.

Primary Care cannot be forced into 10-15 minute time slots to “improve productivity” without destroying good Doctor-Patient relationships, and most likely produce serious errors of omission. If we were to remove all of the unnecessary paper work, the practice of medicine could again become the best of Professions with superior productivity. Primary care would remain attractive to more doctors, be highly effective and reduce the need for excessive dependency on technology and frequent referrals to specialists.

I urge you to abandon the current health reform proposals and return to consider a uniform system that would save money and produce superior care. Please give serious attention to PNHP, Doctor Flowers, and other supporters. Consider their plan – you said, if you have a better plan let me hear it – over 50% of Doctors, and 60% of the public agree.

Sincerely,
David V. Clough, MD
Gloversville, NY

Copy to Congressmen Paul Tonko and Nancy Pelosi. Senators Max Baucus, Harry Reid, Kirsten Gillibrand and Charles Schumer.

Like initiating CPR on a patient who was dead in the field and remained dead on arrival, the effort to resuscitate the “public option” is mistaken and futile.

Once upon a time, proponents of the “public plan option” sought a “Medicare-like” program that might enroll every other person in the nation and thus run private insurers out of business.

“A roadblock to reform” cried the insurance companies.

Now nothing in the bills passed by the House and the Senate bills would erect a public insurer that could possibly influence the insurance market.

The House bill included a feeble government plan, to start in 2013, that would enroll perhaps 2 percent of the nation by 2019. The Senate bill simply nixed the idea altogether.

In reality the “public option” was never much more than a K-street phrase, a shadow-puppet, a political posture. All along proponents of adding a new government-sponsored insurer boasted “talking points” but never offered workable health reform.

But the insurance companies oppose the “public option” and that proves its virtue, its supporters exclaim.

Hello? Of course the insurers oppose it.

Why would the insurers want to yield even 2 percent of the market to a public plan (House bill) when they’ve been given the “option” (Senate bill) of keeping 100 percent of the market? Why would the insurance companies not fight for the whole pie when the White House let slip that it saw the “public option” as simply a bargaining chip in private dealmaking?

But there is something else here.

With its reliance on the magic of the marketplace, the “public option” is simply not a progressive idea.

Consider two examples of how the market performs when private insurers compete with a public plan. Example 1: under Medicare Advantage the private insurers enroll the healthy and dis-enroll the sick and yet cost more per patient than traditional Medicare. Example 2: in Maine, a “public option” insurer known as DirigoChoice, was established in 2003. Thus far it has failed to enroll but a tiny percent of the uninsured, has not reduced costs for insurance, nor reduced overall health spending, nor lessened disparities in care – and this year it has fatally tanked.

In the United States a corporate oligopoly of huge insurers, with near-monopoly control in most locales, dominate the market. A government insurer of any size would simply add yet another bureaucracy to the present byzantine insurance mess.

Does it really make any sense to think that a government plan could give the private insurance companies a run for their money – within the contemporary corporate marketplace – without draconian regulation upon the industry? Even with regulation, as former Cigna executive Wendell Potter explained at the PNHP annual meeting this year, insurance companies simply “flaunt regulations.”

The insurance market cannot be tricked into reforming itself. The health insurance company that wins at the marketplace avoids and jettisons sick and poor patients and enrolls the healthy and the wealthy – and a “public option” will not change this fact. The market that serves the private interests – profiteering at the expense of the sick – would continue to do so.

The proper name for this kind of “market magic” is the race to the bottom. Adding a public plan into the private mix can not and will not change the character of this cruel game.

Any successful “public option” insurance plan would wind up covering the sick and the poor. It would be designed to lose, not win, the market competition. It would not prove affordable or comprehensive. Worst of all, a highly successful “public plan option” could put our nation on a fast-track to permanent two-tiered health services, exacerbating deplorable disparities that plague us.

Regrettably, that the “public option” has been given attention at all is but a measure of how deeply our culture has surrendered to neoliberal ideology, the ideas popularized by Ronald Reagan. It is a lie that the market will always provide, most especially when it comes to health care. So why would some of our friends still seek to revive the false promise of the “public option”?

Marie Gottschalk, University of Pennsylvania Professor of Political Science, identified the psychology at work. In a remarkably prescient essay written in late 2009, she compared health reformers in the United States to victims of the Stockholm Syndrome, in which hostages identify with – and even defend – the hostage-takers.

We ought to reach out with sympathy to our friends who have fallen captive to Ronald Reagan ideology and say – Do not resuscitate the “public option.” It is time to let it go.

All along, adding a feeble public insurance plan to the insurance market has been but a very poor excuse to support “insurance reform” that will criminalize the uninsured, divert billions of tax dollars to subsidize unaffordable private insurance premiums and protect pharmaceutical industry super-profits.

Another world is still possible. It is called Medicare-for-all, expanded and improved.

[An earlier version of this essay appeared at The Progressive and in McClatchy newspapers around the nation.]

This week the sincere effort of millions of people across the nation once again proved effective in the face of determined opposition from the White House and Congress, as single payer health reform reached another milestone in its historic journey.

When the Senate initiated its debate on health insurance reform, Senator Bernie Sanders offered a single-payer amendment, with co-sponsors Sherrod Brown and Roland Burris. Initially Senate Majority Leader Harry Reid skipped over it, allowing other amendments to come to the floor instead.

But nationwide events on International Human Rights Day, the delivery of paper “bodies” to the senate offices, non-violent civil disobiedience including nine arrests at Senator Schumer’s office, and hundreds of thousands of emails and phone calls and faxes to the Senate evidently changed Reid’s mind.

When Sanders introduced his amendment the Senator from Oklahoma, Dr. Coburn, rose according to the rules of the Senate to insist that the bill be read in full. It was estimated that reading the 767-page bill would take days and stall the Senate agenda.

We wondered: Could this be an unexpected gift? If Senator Lieberman could make an intransigent stand on behalf of the insurance companies, would Sanders make a stand on behalf of the people’s health?

Reading the bill would prompt our movement to swing into action yet again. We would invite the nation to tune in to C-SPAN to hear how a national single payer health system would provide comprehensive high-quality health care to all citizens. Yet Coburn’s maneuver had its effect.

Majority Leader Reid demanded that Sanders withdraw the amendment, for the Senate timetable leading up to Christmas could not be delayed. Besides insurance reform, there was the pressing issue of funding the wars. Within 3 hours Sanders agreed. In return he had 30 minutes on the floor.

Sanders’ speech was riveting. He spoke the words that we have been waiting to hear for so long. He spoke about the beauty and simplicity of Medicare for All. He spoke about having the courage to stand up to the medical-industrial complex which profits at the expense of human suffering.

Most importantly, Sanders spoke about the national movement for single payer being led by nurses, doctors, medical students, faith and labor organizations and people across the land of all backgrounds and beliefs. He declared that this strong movement is not going away and he announced that we will succeed.

So we will remember December 16th, 2009 as a turning point in the struggle for health care justice. Single payer started this year “off the table.” But the accumulating efforts of millions of people delivered it to the floor of the United States Senate.

To win single-payer health reform it will take many more speeches on the floor of Congress. And the only force that will propel Congress forward is a great social movement. In 2009 we have seen that movement rising up – and getting results.

Every day more people see that an effective and just health system is already at hand: a single-payer national health program modeled on the Medicare system. And every day that the White House and Congress delay single-payer reform, people suffer needlessly and die preventable deaths. Yet the Senate blunders on, with a colossal gift to the insurance industry.

It is time for the health of human beings to prevail. It is time to end the insurance cartel. Please join us us as we continue forge the movement that will win Medicare for All.

Onward to single payer.

Margaret Flowers is a pediatrician in Baltimore, co-chair of the Maryland chapter of Physicians for a National Health Program (PNHP) and PNHP Congressional Fellow. Andy Coates is an internist in Albany, secretary of the Capital District (NY) chapter of PNHP and co-chair of Single Payer New York.

Get ready for the next liberal excuse for not supporting single-payer: Managed care. Yes, the managed care that infuriated the public with its limits on patient choice of doctor and its interference in the doctor-patient relationship, that induced merger madness throughout the health care industry, and that diminished the quality of care without lowering costs.

Managed care was to the 1990s what the “public option” has been to this decade – an excuse for “yes but” Democrats to turn away from single-payer. Now that it is clear the “public option” is not the politically feasible alternative to single-payer it was cracked up to be, look for “yes but” Democrats and their allies to resurrect managed care as their excuse for not supporting single-payer.

Exhibit A: Washington Post blogger Ezra Klein

The signs that “yes but” Democrats and groups like Health Care for America Now will soon be promoting a new and improved managed care are everywhere, including the legislation they are trying to pass in Congress. The most recent straw in the wind was a brazenly revisionist piece by “public option” advocate Ezra Klein. Klein’s December 7 post called managed care a “tremendous success.”

Klein actually wrote:

This [the 1990s] was the era of the managed-care revolution, which most remember as a horrifying failure. Famously, audiences applauded when Helen Hunt broke out into a profanity-laden rant against HMOs in the movie “As Good as It Gets.” The popular backlash was so intense that by the turn of the century the managed-care experiment was virtually over. The problem with this historic failure? The data showed the experiment to be a tremendous success.

What data might this be? Klein offers none.

Instead he offers this sleight-of-hand:

From 1989 to 1995, median wages actually fell a bit. Then, managed care kicked in. Annual growth in health-care costs fell from more than 10 percent in the early 1990s to less than 5 percent in the late ’90s. Meanwhile, wages shot through the roof, rising more than 11 percent from 1995 to 2000. Then we ended the managed-care experiment, and health-care costs resumed their normal speed of growth. Predictably, wages slumped back down from 2000 to 2006. “By every observable indicator,” says Harvard’s David Cutler, “managed care was a huge success. It cut spending, cut the growth of spending and didn’t seem to kill anyone. And yet everyone hated it.”

There are at least four errors in this sloppy and specious paragraph:

(1) Managed care in fact did inflict enormous harm on many patients;

(2) the test for whether a health care “reform” proposal is acceptable needs to be a tad higher than “it didn’t kill anyone”;

(3) managed care did not “kick in” in 1995, it did not disappear in 2000; and

(4) the evidence does not support Klein’s claim that managed care caused the temporary decline in the annual growth rate of health insurance premiums that occurred in the 1990s.

Managed care did great harm

Can you imagine the uproar that would ensue if a clinic urged patients to accept an unproven treatment or drug on the ground that it “didn’t seem to kill anyone”? Shouldn’t the standard for health care reform be as rigorous as the standards we expect health care professionals to meet? But instead of rejecting, or at minimum questioning, the remarks by David Cutler (who advised candidate Obama), Klein endorsed them.

Klein’s condescending remarks notwithstanding, the American public had good reason for its hostility to managed care. Managed care – a term that refers collectively to the cost-containment tools pioneered by HMOs in the early 1970s – applied to health care spending, particularly in the hospital and mental health sectors, particularly expenditures on patients least capable of defending themselves. The meat axe sliced away necessary medical expenditures as well as unnecessary expenditures.

Why don’t Klein and Cutler base their evaluations of managed care on the scientific literature that examines it? That literature shows managed care damaged quality of care. If they really don’t have time to do the necessary research, perhaps Klein and Cutler could steal a few seconds to take a look at this clip from “Sicko” in which a woman recounts how Kaiser Permanente (the prototype of the American managed care insurance company) delayed the treatment of her daughter until the little girl collapsed and died. If they still have some time left over to do further research, Klein and Cutler might take in this “Sicko” clip in which John Ehrlichman sells HMOs to Richard Nixon with the argument that “all the incentives are toward less medical care, because the less care they give them the more money they make.”

Managed care began in the early 1970s and is still with us

“Managed care” is a term that was first used in about 1985 to refer collectively to three tools pioneered by HMOs like Kaiser Permanente: financial incentives to induce doctors to order fewer services, “utilization review” (which means an insurance company bureaucrat second-guesses decisions made by doctors and patients), and limited choice of doctor and hospital. By the late 1980s the managed care armamentarium included a fourth tool: The threat to refuse to contract with uncooperative doctors, a threat which in the highly consolidated insurance industry could amount to blackballing a doctor from an entire metropolitan area or state.

Following the enactment of the HMO Act of 1973 (endorsed by Nixon as well as leading Democrats), managed care spread slowly throughout the insurance industry over the next decade, and then much more rapidly beginning in the mid-1980s. Managed care was so widespread by 1988 that a paper published in that year in the Journal of Health Politics, Policy and Law concluded, “It is estimated that virtually all third-party payers conduct or sponsor some type of utilization review.” (Danny Ermann, “Hospital utilization review: Past experience, future directions,” 1988;13:683-704). In a report entitled, Effects of Managed Care: An Update, the Congressional Budget Office reported, “In 1990, only 5 percent of people with employment-based health insurance were in unmanaged fee-for-service plans” (see page 9).

In short, the managed-care cancer began spreading in the early 1970s, and had taken over the entire American health insurance industry by 1990. It never “kicked in,” and it most definitely did not “kick in” in 1995.

Nor did managed care get switched off in 2000 as Klein asserts. It is true that in the late 1990s the insurance industry attempted to defuse the “HMO backlash” (which began in the latter half of 1995 and was in full bloom by 1996) by expanding the “networks” of providers patients could choose from, and by initiating a marketing campaign a few years later designed to persuade the public that the industry would forevermore engage in a kinder and gentler form of managed care. Because measuring the extent to which insurance companies use managed care tools is impossible to do accurately, it is difficult to say to what extent the industry actually changed its ways. It does appear that during the late 1990s and early 2000s the industry made less use of utilization review, the most visible and infuriating managed care tool, and relied more heavily on the less visible tool – financial incentives to deny medical services, including bonuses and penalties based on how well providers perform on crude “report cards.”

Managed care did not cause the 1991-1996 inflation lull

Between 1991 and 1996, annual inflation in health insurance premiums dropped precipitously, from 10.9 percent to 0.5 percent, before soaring back to the more usual annual rise of 5 to 10 percent. A large part of this drop was due to a historic 50-percent drop in the underlying (or economy-wide) inflation rate that began in 1991. But the reduction in health insurance premium inflation exceeded the reduction in underlying inflation. What caused this reduction?

The insurance industry and their allies claimed, precisely as Klein and Cutler do now, that the widespread use of managed care tools should get the credit. But those who made this claim could not cite any research showing that managed care in general, or any one of its tools in particular, saved money; they could only point to the rapid takeover of our health care system by managed care during the 1980s, and then the sudden decline in premium inflation beginning in 1991. What the research did show was that insurance companies that adopted managed care tactics tended to cut medical expenditures and drive up administrative costs, for a net effect of approximately no change in total costs.

So if managed care wasn’t the cause of the early 1990s inflation lull, what was? In a paper published in Health Affairs in 2000, I reviewed the evidence indicating managed care saved no money, and then listed four factors having nothing to do with managed care that explained the lull (“On the ‘efficiency’ of managed care plans,” Health Affairs 2000;19(4):139-148):

The mid-1990s lull was caused primarily by the short-term reactions of the industry to the near-simultaneous occurrence of four events: (1) a downturn in the three-years-up, three years-down health insurance pricing cycle; (2) the delayed effect of the 1990–1991 recession; (3) the endorsement of managed competition models of health reform by the White House and numerous state and federal politicians; and (4) the merger fever triggered by these political endorsements. The latter three phenomena deepened and lengthened what otherwise would have been a shallower and shorter downturn in the usual insurance-pricing cycle. (Page 144)

All four of these factors, as well as the decline in the underlying inflation rate, ceased to have a downward effect on premium inflation at about the same time – about 1996. Accordingly, premium inflation began to rise in 1997, just as the “HMO backlash” materialized. Just as some less-than-astute observers thought managed care should get the credit for the decline in insurance inflation rates that began in 1991, so some observers thought the “HMO backlash” should get the blame for the return of higher premium inflation rates in 1997. Those observers were wrong on both counts.

Post-train-wreck debate

The 2009 debate about the Democrats’ proposed health-insurance-industry bailout is nearly over. It has been clear since June 2009, when the Democrats in both houses of Congress unveiled their versions of the health insurance industry bailout legislation, that whatever Congress passes in 2009 or 2010 will do nothing to cut health care costs and, therefore, will at best leave perhaps half of the uninsured twisting in the wind for who knows how long. Because the Democrats’ proposed legislation does nothing to “bend the cost curve,” to use Beltway jargon, cost containment will dominate the next stage of America’s endless health care reform debate. Unlike the “public option” and managed care, single payer reform would cut costs by hundreds of billions of dollars and would cover everyone.

Klein’s endorsement of Cutler’s fantasies about managed care is one of many signs that a “new and improved” version of managed care will supplant the “public option” as the focus of the cost-containment debate among the “yes but” Democrats and as the “yes buts’” next excuse for not supporting single-payer. We can look forward to this because the “public option” proved so unpopular with the insurance industry and the right wing, and because the insurance industry loves managed care. We should expect this shift to occur in 2010. Unfortunately, we should also expect the “yes buts” to flog Managed Care 2.0 with the same sloppiness and disregard for empirical evidence that they displayed in their campaign for the “public option.”

Kip Sullivan serves on the steering committee of the Minnesota chapter of Physicians for a National Health Program.

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).

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?”

Jacob Hacker’s ambiguous polls
By Kip Sullivan, JD

In Part 2 and Part 3 of this series I reviewed rigorous evidence from multiple sources supporting the statement that somewhere between 60 and 80 percent of Americans support a Medicare-for-all system. A reasonably conservative averaging of the more rigorously conducted research I reviewed – the citizen jury results and the results of polls that asked accurate and relatively informative questions – indicates two-thirds of Americans support a single-payer or Medicare-for-all system.

In this part and in Part 5, I will examine the basis for the claim by representatives of the “public option” movement that only a minority of Americans support single-payer and a majority are opposed. The basis for that claim consists primarily of several papers written by Jacob Hacker and “research” done for the Herndon Alliance by pollster Celinda Lake. Until about two years ago, Hacker wrote about health policy primarily for the academic community; since then he has published frequently in the lay media. Since its formation in 2005, the Herndon Alliance has sought to create “research” that could be used to persuade the public, especially legislators and political activists, that single-payer should be taken off the table and the “public option” should be put on the table. I review Hacker’s work in this paper and Celinda Lake’s in Part 5.

Expediency-driven health policy

It may sound sacrilegious to say this …, but the greatest lesson of the failure of the Clinton health plan is that reformers pay too much attention to policy and too little to politics. If real estate is about location, location, location, health reform is about politics, politics, politics.

Thus spake Jacob Hacker in a paper published in Health Affairs in 2008 entitled, “Putting politics first.” Hacker argues that anyone who wants to achieve universal health insurance must somehow separate “politics” from “policy” and give highest priority to politics. If Hacker had merely said that anyone who seeks to achieve universal health insurance should devote resources to building public pressure for it, his statement would be incontrovertible. It would be a truism. But Hacker’s “politics, politics, politics” statement went beyond the truism that “reformers” must build a movement for universal health insurance.

Hacker’s demand that we distinguish between politics and policy and give high value to one and low value to the other is nonsensical. It’s equivalent to saying that process is separate from and matters more than outcome, or that means are separate from and matter more than ends. To make such a distinction amounts to an endorsement of opportunism and expediency. We will see in the remainder of this article that in fact that’s where Hacker’s “put politics first” mantra leads him. It leads him to attribute to the public anti-single-payer, pro-insurance-industry attitudes based on polling data that are so abstract they offer no guidance at all. As the events of 2009 have demonstrated, the exaltation of expediency – dressed up as political science – produces neither good policy nor good political strategy.

Unlike the Herndon Alliance, which commissioned its own polling and focus group “research,” Hacker relied on existing polling data to support his conclusion that single-payer is not feasible while the “public option” is. Hacker cites different types of polls depending on whether he is addressing the general public or health policy experts. His 2006 article for Slate cited one set of polls. A 2007 paper that he co-authored with Mark Schlesinger (“Secret weapon: The ‘new’ Medicare as a route to health security,” Journal of Health Politics, Policy and Law 2007;32:247-291) cited another set of polls. Inexplicably, neither paper discussed the Jefferson Center jury results I discussed in Part 2 nor the polls showing large majorities for single-payer that I discussed in Part 3 of this series.

In the course of examining these two papers, I will review in detail seven polls that Hacker cites. This may get tedious, but it’s important that you see for yourself how nebulous Hacker’s “evidence” is. Once you behold Hacker’s “evidence” directly, you realize that Hacker’s belief that Americans oppose single-payer is based entirely on polling results that resemble a Rorschach ink blot. You can see in them what you want to see. Where you and I might discern a public ready to support single-payer, Hacker discovers hulking impediments to single-payer.

Polls Hacker cited in his Slate article

Hacker’s article for Slate bore the condescending title, “Better medicine: Fixing the left’s health care prescription.” The problem in need of “fixing,” according to Hacker, was “the left’s” support for single-payer. Hacker urged “the left” to support instead his proposal to “give employers the option of providing … coverage to their workers through a new public program modeled after Medicare” or through the insurance industry, a proposal that would, by 2009, be called “the public option” for short.

Hacker grudgingly acknowledged single-payer’s advantages, but then claimed single-payer advocates were “biting off too much.”

Americans like Medicare, and yes, Medicare is easy to explain. But that doesn’t mean most people are ready to say everyone should be covered by Medicare. Many of us remain stubbornly attached to employment-based health insurance, and proposing to abolish it entirely is likely to stir up fear as well as gratitude.

He hyperlinked the words “stubbornly attached” to an article in Mother Jones written by the Century Foundation. (In the fullness of time, the Century Foundation became a passionate advocate for the “public option.”) The Century Foundation article reviewed several polls on American attitudes about “universal coverage.” Amazingly, one of them was the 2003 Washington Post/ABC News poll showing 62 percent support for a Medicare-for-all system that I discussed in Part 3. Does Hacker read the documents he cites as evidence for his own claims?

Before we examine the Century Foundation’s article, I want call your attention to three features of Hacker’s argument.

First, he practices “put politics first.” He says that even though single-payer is a good proposal, it should be rejected entirely. It would be one thing to counsel single-payer advocates against trying to get a full-blown single-payer system enacted in a single session of Congress and to plan instead for a multi-year campaign (which is fact what the single-payer movement has been doing for two decades). But Hacker is not doing that. He is urging progressives to reject single-payer completely.

Note second that Hacker urges us to accept whatever polls say as the final arbiter of what is politically feasible. Hacker has no interest in a very obvious question: If everyone who supports universal coverage threw their weight behind the campaign for single-payer, how much higher could public support for single-payer be raised?

Third, Hacker can’t bring himself to say how many Americans are “stubbornly attached” to employer-based health insurance. He can only bring himself to say “many.” If Hacker is going to rest his entire argument that the “left” should abandon single-payer on the premise that “we” are “attached” to the current system, why is he so vague about what proportion of the populace he is talking about?

I urge readers to examine the Century Foundation article for yourself. Focus on the “What we know” section (it’s only a page long), which is where the poll results are discussed. It will become obvious quickly that this article provides no basis at all for Hacker’s claim that Americans are “stubbornly attached” to the current system. At most, only three paragraphs have any relevance to that claim, and these paragraphs produce results that are at best ambiguous and at worst (from Hacker’s point of view) supportive of single-payer.

Consider the two excerpts from the Century Foundation summary I quote below. The first asserts the public wants to replace “the current employer-based system” (yes, the very same “employment-based” system to which Hacker says “many of us remain stubbornly attached”). The second excerpt, which appears barely a half-page later, asserts just the opposite.

[Excerpt 1]
The public wants the government to play a leading role in providing health care for all. For example, in an October, 2003 Washington Post/ABC poll, by almost a two-to-one margin (62 percent to 33 percent), Americans said that they preferred a universal system that would provide coverage to everyone under a government program, as opposed to the current employer-based system.

[Excerpt 2]
The public generally wants to build on, rather than eliminate, the current employer-based private health insurance system. In a January, 2000 Kaiser poll, they preferred building on the current system to switching to a system of individual responsibility (54 percent to 39 percent) and in a November 2003 Kaiser poll, they preferred keeping the current system to replacing it with a government-run system (57 percent to 38 percent). (emphasis added)

How does one make any sense of these conflicting statements? How does Hacker find in these statements proof that Americans (a) like the current employer-based system, and (b) like it so much they would oppose a single-payer system? In these excerpts, the author of this summary, Ruy Teixeira, gives us not only two contradictory statements to sort out (the public does and does not want to replace the “current employer-based system”), but we’re supposed to understand what “a system of individual responsibility” and “a government-run system” means.

If we track down the polls these excerpts refer to, we discover that we have already encountered these polls, or polls like them, in Part 3 of this series.

I discussed in Part 3 of this series the 2003 Washington Post/ABC poll that Teixeira cites in the first excerpt. That poll found 62 percent support for a single-payer system, described in that poll as “a universal health insurance program, in which everyone is covered under a program like Medicare that’s run by the government and financed by taxpayers.” So how does Teixeira account for the difference between the 62 percent support for single-payer he reports in the first excerpt and the 38 percent level of support one or both of two Kaiser polls (Teixeira isn’t clear which) reported for a “government-run system” in the second excerpt? He doesn’t say.

The Kaiser poll search engine (using the phrases “individual responsibility” and “government run”) and a Google search turned up only one of the two Kaiser polls Teixeira refers to in excerpt 2 above – the January 2000 poll. That poll, which Teixiera cited as evidence that Americans prefer “the current system” to a “system of individual responsibility,” reads as follows:

Which of the following, option one or option two, do you think would be the better way to guarantee health insurance coverage for Americans? Option One is, building on the current system in which employers contribute to their employees’ health insurance, which they get through their job, and the Government covers the cost of insurance for the poor and unemployed, or Option Two which is, switching to a system in which all individuals would buy their own health insurance but would receive a tax credit or subsidy to help them with the cost of the plan.

Fifty-four percent chose “the current system” versus 39 percent who chose what Teixeira called “a system of individual responsibility.”

In my last installment I discussed polls quite similar to the other (2003) Kaiser poll Teixeira cited (the one my search failed to turn up), a poll which, according to Teixeira, asked respondents to choose between “the current system” and “a government-run system.” The ominous phrase “government-run system” sounds very much like the frightening phrase “government-run health care system” conjured by the Gallup poll (discussed in Part 3). The 38-percent level of support Teixeira reports is within the range of Gallup poll results over the last decade – 32 to 41 percent – that I reported. This strengthens my hypothesis that the question Teixeira claims Kaiser asked in 2003 was very similar to the Gallup question. (It would help if people who urge readers to rely on polls for any reason would link readers to those polls or give more precise source information.)

The only other shred of information in the Century Foundation article that might give a “yes but” comfort was this excerpt, which again contained contradictory statements:

In a December 2003 Harvard School of Public Health/Robert Wood Johnson/ICR poll, 80 percent supported expanding Medicaid/SCHIP; 76 percent supported employers being required to offer a health plan; and 71 percent supported a tax credit plan. Trailing these options, but still garnering majority support, were a universal Medicare plan (55 percent) and an individual coverage mandate plan (54 percent). …. (Note: one of the only options that didn’t garner majority support … was a single or national health plan financed by tax payers that would provide insurance for all Americans [37 percent to 47 percent].)

Once again, Teixeira juxtaposes a poll showing majority support for single-payer (55 percent) with another poll showing 37 percent support, and offers no explanation for the difference. As you can see, the two single-payer questions Teixeira refers to appear to have been part of a line-up of another half-dozen questions or so, including questions about proposals that wouldn’t come close to achieving universal coverage and none of which would cut costs.

To sum up, the Century Foundation article Hacker linked his readers to for evidence of our “stubborn attachment” to the current system demonstrated nothing of the sort.

Polls Hacker relies on in his 2007 paper

In the paper he published in the Journal of Health Politics, Policy and Law in 2007 with Mark Schlesinger, Hacker argued for the “public option” and against single-payer. As he did in his Slate paper, Hacker argued that the “expectations” and “values” of the American people, not the insurance industry, constitute an intractable obstacle to single-payer. At the outset of this paper, in a section entitled, “Prevailing American values as barriers to universal health insurance,” Hacker sought to make two arguments: Americans value choice of health insurance company, and they are scared of their government. The data he relied on to make this case were even more abstract and ambiguous than the data he relied on in his Slate article. I’ll review the evidence he cites for his claim that Americans value choice among insurance companies first, and then examine the data he cites for his claim that Americans are afraid of a single-payer system.

Hacker’s argument that Americans value choice of health insurer (as opposed to provider) consisted almost entirely of these statements:

During the debate over health reform in the early 1990s, 81 percent of the public reported that it was important or essential for a proposal to give “people a choice of different types of health insurance plans” (Louis Harris and Associates in 1994). When asked whether “seniors should have the option of picking a private health plan approved by the Medicare program to provide their health benefits,” 82 percent of the public endorsed these choices (Zogby International 2003). Americans embrace choice of insurance not because they favor markets in health care per se but because they have so little trust in government, employers, or private insurance and want protection against problematic experiences (Blendon et al. 1998; Jacobs and Shapiro 1999).

Neither of the two polls and neither of the two papers Hacker cites support his conclusions. The papers deal exclusively with the backlash against managed care that occurred in the late 1990s. Those papers say nothing that could be construed as evidence that Americans “embrace choice of insurance” and have “little trust in government.” To give you some idea of how badly Hacker misinterpreted these papers, I have presented the abstract of the paper by Blendon et al. in the appendix to this paper (the Jacobs and Shapiro paper did not contain an abstract).

Now let’s look at the two polls Hacker cited to support his claim that Americans value choice of insurance company. The 1994 Harris poll posed this question:

As the Congress debates health care reform, they must consider several different goals. Please say for each of the following whether you think it is absolutely essential, very important, or not important …. Giving people a choice of different types of health insurance plans?

Thirty-six percent said “choice of… plans” was “absolutely essential” and 45 percent said it was “very important.” But does this poll demonstrate that Americans value choice of insurance company?

This poll was conducted during May 23 to 26, 1994, while the debate over the Clinton bill – a bill which would have pushed middle- and lower-income people into HMOs and other tightly managed health insurance companies – was still in full swing. The poll question deliberately asked respondents to think about the current debate in Congress and the “goals” that “Congress must consider.” The context in which this poll question was asked, and the opening statement to the question, must have induced all or most respondents to think they were being asked whether they would approve of Congress reducing their choice of insurance companies. It is not surprising they said no to this question. But saying no cannot be construed as “attachment” to the current system, and certainly not opposition to Medicare-for-all. Hacker’s claim to the contrary is equivalent to saying prisoners in a gulag are “stubbornly attached” to gulag food because they told a pollster they would object to being given less of it. (This question and the responses were emailed to me by the Roper Center for Public Opinion Research at the University of Connecticut.)

The other poll Hacker refers to – a Zogby poll – misled respondents. The poll, conducted June 18-21 2003, asked if “seniors should have the option of picking a private health plan approved by the Medicare program to provide their health benefits.” But the poll failed to ask respondents if they would feel the same way if they knew that allowing insurance companies to insure Medicare beneficiaries raises the cost of the entire Medicare program. This is a very well documented fact; every expert knows it to be true. Even Hacker and Schlesinger acknowledged it. How far support would have fallen had respondents been informed that their taxes would have to go up to give seniors the privilege of leaving the traditional Medicare program and enrolling with an insurance company? We don’t know. Zogby didn’t ask, possibly because the conservative Galen Institute was the sponsor of the poll.

Now for Hacker’s and Schlesinger’s claim that Americans are afraid of a government-financed single-payer. This claim relied primarily on two polls conducted over several decades: the “General Social Survey,” conducted by the University of Chicago, and the “National Election Studies” survey conducted by the University of Michigan.

Hacker and Schlesinger claimed the General Social Survey supported the following baffling statement:

“[W]hile approximately 80 percent of the public endorses some collective responsibility for health care finance, support for a completely collective role rarely garners majority support and, if so, then for only brief periods of time (see Figure 1)” (page 252).

What does “some collective responsibility” mean? How does it differ from “complete collective responsibility”? The latter seems to mean government pays for 100 percent of the national health care bill. But no country in the entire world does that. What does “health care finance” refer to? Universal coverage? Less-than-universal coverage? A single-payer system? The current multiple-payer system?

The figure Hacker and Schlesinger refer to as evidence for this baffling statement is a bar chart, based on the General Social Survey, showing bars for various years broken down by the proportion of the populace who support “collective,” “individual,” and “split responsibility for medical care.” The figure indicates that from 1975 through 2000 roughly 50 percent of Americans supported “collective responsibility,” 30 percent supported “split responsibility,” and 20 percent supported “individual responsibility.” How any reasonable person can conclude from these data that Americans oppose single-payer because they fear government and value choice of health insurance company is beyond me. If we really must ask whether such ambiguous data dictate that we abandon or support a Medicare-for-all system, it would seem more reasonable to interpret these data to say a majority of the public will support Medicare-for-all.

To enhance your impression of how flimsy this bar chart is, consider the actual question asked by the GSS survey:

In general, some people think that it is the responsibility of the government in Washington to see to it that people have help in paying for doctors and hospital bills. Others think that these matters are not the responsibility of the-federal government and that people should take care of these things themselves. Where would you place yourself on this scale [respondents were handed a card showing numbers running horizontally from 1 to 5], or haven’t you made up your mind on this?

Above number 1 on the card is the label, “I strongly agree it is the responsibility of government to help” and above number 5 is the label, “I strongly agree people should take care of themselves.”

Similarly, Hacker and Schlesinger use data from the National Election Studies survey that is at best ambiguous and at worst (from Hacker’s point of view) favorable to single-payer to spin a picture of Americans so “deeply divided” about the role of government that single-payer isn’t possible. They claim that a single question from this survey supports the following conclusions:

“Americans have long been deeply divided about their preferred approach to expanding health insurance…. Americans … split evenly between those who favor administration of insurance benefits by the government and those who prefer subsidies for private insurers (table 2)” (page 255).

The table they refer to shows that over the last half century roughly 45 percent favor “government insurance” versus about 40 percent for “private insurance.” Here is the question:

Some people feel there should be a government insurance plan which would cover all medical and hospital expenses for everyone. Others feel that all medical expenses should be paid by individuals, and through private insurance plans like Blue Cross and some other company paid plans. Where would you place yourself on [a seven-point] scale…. ?

There was, of course, no other information to help respondents interpret the key phrases in this question including “government insurance plan.” Respondents had to rank themselves as a “1” if they were strongly in favor of a “government insurance plan” that paid all expenses for everyone, and 7 if they felt strongly in favor of “individuals and private insurance plans” paying some unspecified portion of expenses, or some number in between if they felt less than strongly about their opinion. Hacker and Schlesinger treated everyone who ranked themselves as a 4 as undecided, and then treated all the 1, 2, and 3 people as for “government” and all the 5, 6, and 7 people as for “private insurance.”

Summary

Even if we didn’t know that Hacker was an avid proponent of the “politics, politics, politics” mantra, and that this mantra amounts to little more than an excuse to make policy decisions based upon ambiguous and cherry-picked polling data, we might reach these conclusions simply by reading the two papers by Hacker I have reviewed here. In his 2006 article for Slate, and his 2007 paper for the Journal of Health Politics, Policy and Law, Hacker urged his readers to abandon single-payer based on poll results that were not merely cherry-picked (with one unintended exception he excluded polls that showed two-thirds support for single-payer), but, even after careful cherry-picking, were still unclear in their implications.

I am not saying polling data reveal that only a single-payer system attracts majority support. A fair reading of the polls (although not the citizen jury results) suggests that Americans would accept a variety of solutions to the health care crisis if they could be convinced that they would cover everyone and bring costs down.

I strongly disagree with Hacker, however, that the polling data demonstrates a majority wants to defend the current employer-based multiple-payer system and oppose a single-payer system. And I strongly disagree with the assumption that people who care about solving the health care crisis should examine polls first and then decide how to solve the health care crisis. If we must put our finger in the wind before we decide whether to support single-payer, then let us at least consult research that used rigorous methodology, e.g., the citizen juries, and polls that inform their respondents about actual proposals. Let us not consult polls that use vague phrases like “people should take care of these things themselves.”

~~~~~~~~~~~~~~~~~~
Appendix: Abstract of one of two papers Hacker misrepresented

In his paper with Mark Schlesinger published in the Journal of Health Politics, Policy and Law in 2007, Hacker cited two papers for support of this sentence: “Americans embrace choice of insurance not because they favor markets in health care per se but because they have so little trust in government, employers, or private insurance and want protection against problematic experiences.” Neither paper discussed lack of trust in government or employers. Both papers were about public hostility to the insurance industry. Below I present the abstract of one of the two papers (there was no abstract for the second one).

This paper examines the depth and breadth of the public backlash against managed care and the reasons for it. We conclude that the backlash is real and influenced by at least two principal factors: (1) A significant proportion of Americans report problems with managed care plans; and (2) the public perceives threatening and dramatic events in managed care that have been experienced by just a few. In addition, public concern is driven by fear that regardless of how well their plans perform today, care might not be available or paid for when they are very sick. (Robert Blendon et al., “Understanding the managed care backlash,” Health Affairs 1998;17(4):80-94))

Stay tuned for Part 5: Celinda Lake’s “research” for the Herndon Alliance