Two-thirds of Americans support Medicare-for-all (#4 of 6)
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.
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.
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.”
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
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Taming the Deficit
Saving Our Children from Themselves
By David Rosnick and Dean Baker
Center for Economic and Policy Research (CEPR)
Understanding the Deficit
One of the most popular causes among Washington political insiders is reducing the budget deficit. The conventional story in these circles is that current and projected future deficits will place an unbearable burden on future generations. Their argument is that the need to reduce the deficit is a question of intergenerational equity.
The leading spokespeople for this position, such as David Walker, the President of the Peter G. Peterson Foundation, often refer to the country’s $62.1 trillion “real federal financial hole.”
However, it seems that very few people have a clear understanding of this debt figure. This figure is not in any way a measure of money transferred from younger generations to older generations. In fact, rather than being a measure of how much debt older generations will pass on to today’s young people, to a large extent this ominous debt figure is actually a measure of the debt that today’s young people are projected to run up given the current structure of existing programs, most importantly Medicare. In other words, the huge debt numbers that are being used to scare the country – especially the young – are largely projections of how much debt today’s young will pass onto future generations.
The Cause of the Projected Debt
There are two reasons why later-age cohorts are projected to add more to the debt than the generations that preceded them. First, life expectancy is increasing decade by decade and is projected to continue to do so. Life expectancy after age 65 is currently 18.9 years. It is projected to be 23.2 years in 2085. If the tax and benefit formulas for Social Security and Medicare remain unchanged, then the benefits received in these programs will rise through time, as workers collect benefits for a longer period of time.
However, increasing longevity is a relatively minor factor in the rising deficit projections. The main factor is that per person health care costs are projected to far outpace the rate of per capita GDP growth. In other words, the main reason that today’s young and those yet to be born are projected to impose a far larger burden on the government than their parents and grandparents is that their health care is projected to be far more costly.
If the United States had health care costs that were in line with those of other wealthy countries, then the projections would show enormous surpluses, not deficits. Figure 3 shows long-term budget projections for the United States and then adjusts these projections under the assumption that it has the same per capita health care costs of Germany, Canada, Spain, and the United Kingdom.
As can be seen in all of these cases, the United States is projected to run enormous surpluses. For example, if the United States had the same per capita health care costs as Canada, its budget surplus would be equal to 0.13 percent of GDP by 2050. By 2080, its budget surplus would be 2.52 percent of GDP. In short, the budget problem facing the United States is almost entirely an issue of dealing with an out of control health care system, not the old stealing from the young.
It has been said the the profligacy of our boomer generation, in wanting to keep our Medicare and Social Security benefits, is resulting in an intergenerational transfer that will drown our children and grandchildren in debt racked up by the tsunami of federal budget deficits caused by these two programs.
The potential is very real, but the framing is flat out wrong because it leads to advocacy of policies that could not be more damaging: cut Social Security benefits and make even deeper cuts in Medicare benefits.
Social Security is not a problem. The program requires little more than a few tweaks to make it solvent forever.
Medicare is the problem, but it is not due to our overuse of health care services. Our level of use is comparable to other nations. It is the outrageous rate of health care inflation that is the driving force that will create intolerable deficits in the future. We do not need to eliminate beneficial health care services. We need only to tame health care inflation, just as every other nation has already done by adopting some form of social insurance.
Because we are way behind schedule, with health care inflation already taking a heavy toll, we should not accept the less efficient models of social insurance but instead try to make up with a more efficient version – a single payer Medicare for all.
This report should be downloaded since it is invaluable as a resource to educate others. In fact, right now click on the link and quickly look at Figure 3 (cited above). That alone should motivate you to retain this report and share it with others.
We do have an obligation to our children and grandchildren, though it is not in declining the intergenerational transfer to finance our programs that provide us with security in retirement. Our obligation is to create and transfer to them a health care financing program that will ensure that they always will have the security of health care without the insecurity of mounting debt to pay for it. We need to transfer to our progeny a financing system which will save them from THEIR deficit.
By Gabe Bullard
WFPL News, December 10, 2009
KY- About ten area residents gathered in Louisville Thursday to voice support for a single-payer health care plan.
Many of the same demonstrators have held similar protests in the last few months. This particular demonstration was one of about 20 held across the country to mark Human Rights Day.
The protestors are unhappy with the compromises many Democrats have made to the current healthcare overhaul proposal. Harriette Sieler is the secretary of Kentuckians for Single-Payer Healthcare. She says she’s also not happy with the debate surrounding the legislation.
“Right now in Congress they are saying the eligibility age of Medicare to 55,” she says. “I say lower it to zero.”
The group gathered outside of Senator Mitch McConnell’s office downtown.
Dr. Garrett Adams with Physicians for a National Health Program took issue with Senator McConnell’s recent statement that he hasn’t heard from any Kentucky doctors who support the healthcare overhaul.
“Mr. McConnell’s statement is not correct,” he says. “The facts belie his statement that physicians do not support national healthcare, because they do.”
McConnell is among the proposal’s opponents. He says, among other things, the plan would be too expensive.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
New Report Highlights Medicare Advantage Insurers’ Higher Administrative Spending
Committee on Energy and Commerce
U.S. House of Representatives
December 9, 2009
Today Energy and Commerce Committee Chairman Henry A. Waxman and Oversight and Investigations Subcommittee Chairman Bart Stupak released a new report which found that 34 Medicare Advantage insurers expend significant sums on profits, marketing, and other corporate expenses.
The report found:
From 2005 through 2008, the average Medicare Advantage insurer spent over 15% of premium revenue on profits, marketing, and other corporate expenses. Two-thirds of the Medicare Advantage insurers surveyed by the Committee had a medical loss ratio below 85% during at least one of the four years examined. Six of the insurers had medical loss ratios below 75% in one or more years. In comparison, traditional Medicare spends less than 1.5% on administrative expenses and over 98% on health care. In the aggregate, the Medicare Advantage insurers spent $1,450 per beneficiary in 2008 on profits, marketing, and other corporate expenses, nearly ten times as much as traditional Medicare spent on administrative expenses per beneficiary.
Requiring all Medicare Advantage insurers to have a medical loss ratio of 85% would provide billions of dollars in additional medical services to seniors. The total amount spent on profits, marketing, and other expenses by Medicare Advantage insurers over the last four years was $27 billion. The House health care reform bill requires Medicare Advantage plans to spend at least 85% of their total premium revenues on medical claims. If this threshold had been in effect from 2005 through 2008, the Medicare Advantage insurers would have spent an additional $3 billion on their beneficiaries’ medical care, enough to eliminate all copays for preventive care for all Medicare beneficiaries for ten years.
In 2007 and 2008, Medicare Advantage insurers with medical loss ratios lower than 85% paid their executives over $1.2 billion. In 2007, a company that had a medical loss ratio of 79% paid an executive over $35 million. The same company paid 16 more executives salaries and bonuses worth $1 million or more. Another company with a medical loss ratio of 79% paid more than $210 million in compensation to 260 executives.
Medicare Advantage insurers have spent millions on expensive retreats. In 2007, one company with a medical loss ratio of 83% spent $3.1 million for two events in Hawaii. In 2007, a company with a medical loss ratio of 84% spent $2.5 million on employees and agents at a retreat in San Jose del Cabo, Mexico and $1.4 million on an event in Rome, Italy. In 2008, a company with a medical loss ratio of 82% spent $1.5 million on a meeting in Edinburgh, Scotland and $1.8 million on a trip to Cancun, Mexico.
Congress and the Obama administration decided up front that reform would be based on private insurance plans, rejecting without consideration the single payer Medicare for all model.
They are proposing innovative pilot programs as experiments in containing health care costs, glossing over the logistical nightmares and the lack of a foundation in policy science, as they move forward with these untested policies. Yet they have right in front of them one of the most important, most expensive, and most credible real-life experiments ever conducted: contrasting the government Medicare model with the private Medicare Advantage insurance plans.
In comparing traditional Medicare with Medicare Advantage, we need to set aside from consideration the funds that are used to pay for actual health care since these are our funds merely held in trust for the payment of medical bills. What we need to compare are the costs of the administrative services that are being provided by each entity.
The experiment has been completed, and the results are in. The private Medicare Advantage insurers spend nearly ten times the amount per beneficiary that is used to administer the government Medicare program. TEN TIMES!
Some might say that we aren’t being fair because some of the ten fold increase in spending goes to profits and to expensive retreats for the private insurance executives, whereas the traditional Medicare program doesn’t have those obligations. In this instance, what’s fair in the business community is fraud in the government.
Congress has the results of this study. The report has been generated by one of its own committees. Our legislators have a fundamental moral obligation to study this crucial real-life experiment. They then need to act upon it instead of upon the magical thinking behind the nebulous pilot projects.
In fact, even this report contains one such flawed policy recommendation. They recommend that the private insurers be limited to 15 percent of the insurance pool to use for administration and profits. That is still about eight times the administrative costs of Medicare. EIGHT TIMES! Is that the best that Congress can come up with?
Medicare is already under attack for its perceived parsimoniousness. Since the pilot projects would be designed to further reduce spending within the Medicare program, that perception would be amplified, seriously threatening the support of the health care providers.
We first need the broad, solid infrastructure of single payer Medicare for all and only then should we consider new pilot projects that are based on sound policy science that would work for all of us, providing quality care while protecting our finances. The probability of getting the policies right would be much greater in a single system in which patients, providers and the government are all working together toward a common goal: quality, affordable health care for all.
There is something for those who disagree: a little vicarious serendipity. You can check out the brochures and websites of the expensive resorts, and then close your eyes, lean back and dream about the great time that the insurance executives are having with the money you paid them in the form of excessive insurance premiums. Pleasant dreams.
Two-thirds of Americans support Medicare-for-all (#3 of 6)
Informative polls show two-thirds support for single-payer
By Kip Sullivan, JD
In Part 2 of this six-part series, I reported on the results of two “citizen jury” experiments in which advocates for single-payer, managed competition, and high-deductible policies spoke to, and were questioned by, “juries” that were representative of America. In the case of the 1993 “jury” sponsored by the Jefferson Center, 71 percent voted for single-payer. In the case of the 1996 “jury,” 61 percent voted for single-payer when no specific information about its cost to individuals was presented, and 79 percent voted for a single-payer system that would have lowered premium and out-of-pocket costs by as much as taxes rose. Both juries rejected proposals relying on health insurance companies by huge majorities.
Many polls that ask about support for Medicare-for-all produce results that confirm the citizen jury findings. But others don’t. What explains that inconsistency?
The more they know about single-payer, the more they like it
In this paper (Part 3 in a six-part series) I will present data from polls that ask about single-payer, and then inquire why some polls show landslide majorities for single-payer and some do not. We will find a clear pattern: Polls that convey more information tend to report higher levels of support than polls that convey little information, and polls that convey accurate information tend to report more support than polls that convey inaccurate information.
Table 1 lists 14 poll questions taken from 11 polls conducted over the last two decades which used the phrase “single payer” and/or referred to an existing single-payer system (Medicare, for example). All 14 questions found majority support for single-payer.
Three of these polls (representing one question each) were limited to doctors. I have included these physician surveys to debunk the false impression (created primarily by the American Medical Association) that the average doctor is opposed to single-payer. The three polls shown in Table 1 indicate that support among doctors is about 60 percent.
Table 1 indicates that public support for single-payer ranges from a low of 50 percent to a high of 69 percent. I have divided the polls of the general public into those that found support levels at 60 percent or higher (eight questions) and those that found levels in the 50-to-58 percent range (three questions).
Table 1: Polls indicating majority support for single-payer
……………………………………………………………For single-payer……..Opposed to single-payer
General public: Polls in which support is 60 percent or higher
Harvard University/Harris (1988)(a)……………………61%…………..not asked
LA Times (1990)(b)…………………………………………….66%………….not asked
Wall Street Journal-NBC (1991)(c)……………………….69%…………….20%
Wash Post-ABC News (2003)(d)…………………………..62%………….not asked
Civil Society Institute (2004)(e)……………………………67%……………..27%
AP-Yahoo (2007)(f)……………………………………………..65%…………..not asked
Grove Insight (2009)(g)………………………………………64%……………..28%
Grove Insight (2009)(g)………………………………………60%……………..27%
General public: Polls in which support is below 60 percent
Kaiser Family Foundation (2009)(h)……………………..58%……………….38%
Kaiser Family Foundation (2009)(h)……………………..50%……………….44%
New Eng J Med (medical school faculty and students) (1999)
Arch Int Med (doctors) (2004)………………………………64%…………….not asked
Minnesota Med (doctors) (2007)……………………………64%…………….not asked
(a) The question asked by the Harvard University/Harris poll was described in the Health Affairs article reporting the results as follows: “The majority of Americans (61 percent) state they would prefer the Canadian system of national health insurance where ‘the government pays most of the cost of health care for everyone out of taxes and the government sets all fees charged by hospitals and doctors….’” An analogous question posed to Canadians found that only 3 percent of Canadians said they would prefer the American system.
(b) The question asked by the Los Angeles Times poll was: “In the Canadian system of national health insurance, the government pays most of the cost of health care out of taxes and the government sets all fees charged by doctors and hospitals. Under the Canadian system – which costs the taxpayers less than the American system – people can choose their own doctors and hospitals. On balance, would you prefer the Canadian system or the system we have here in the United States?” Sixty-six percent chose the Canadian system and 25 percent chose the US system.
(c) The question asked by the Wall Street Journal-NBC poll was: “Do you favor or oppose the US having a universal government-paid health care system like they have in Canada?”
(d) The Washington Post-ABC News poll asked: “Which would you prefer – (the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance); or (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?)” Thirty-three percent preferred the current system while 62 percent preferred the “universal system.”
(e) The Civil Society poll asked: “Other major nations, such as Canada and England, guarantee their citizens health insurance on the job, through government programs, or via a nonprofit source. Would it be a good or bad idea for the United States to adopt the same approach to providing health care to everyone?”
(f)The AP-Yahoo poll asked two questions. One asked respondents which of these two proposals they agreed with: (1) “The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers” (65 percent chose this option); (2) “The United States should continue the current health insurance system in which most people get their health insurance from private employers, but some people have no insurance” (34 percent chose this option). The second question was: “Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?” (54 percent said they were supporters of single-payer and 44 percent said they were opposed).
(g) The Grove Insight poll asked two questions. One asked: “Federal leaders are considering expanding Medicare to all Americans, so that people have another option besides private health insurance or an HMO. Do you favor or oppose the creation of this type of public health plan option?” (64 percent said they favor this proposal). A very similar question was asked which differed from the first by including information on the financing mechanism: “There is proposed federal legislation that gives any American, regardless of age, the option of joining the Medicare program. Americans who choose this option would share the cost of the coverage with their employer through increased Medicare payroll deductions, instead of paying private health insurance premiums. Do you favor or oppose this legislation?” (60 percent favored it and 27 percent opposed it). Both questions, especially the second one, imply private insurers will continue to exist alongside a Medicare program open to all. But the questions are so similar to questions that clearly ask about Medicare-for-all systems that I decided to include them here.
(h) The Kaiser Family Foundation poll asked: “Now I’m going to read you some different ways to increase the number of Americans covered by health insurance. As I read each one, please tell me whether you would favor it or oppose it.?” This was followed by eight proposals which, with the exception of the question about the “public option,” were asked in a random order (the “option” question was always asked at the end). Two of these questions asked about single-payer. The first read: “Having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for all.” Fifty-eight percent said they favored this proposal while 38 percent said they opposed. The second read: “Having a national health plan – or single-payer plan – in which all Americans would get their insurance from a single government plan.” Only 50 percent favored this proposal while 44 percent opposed.
For sources see Table 2 below.
If we examine the questions posed by all the polls of the general public, one difference between the two sets of poll questions jumps out immediately: The questions that generated levels of support at 60 percent or higher mentioned one of three existing single-payer programs – the Canadian system, the British system, and the US Medicare program. (I have bolded the words referring to these systems in the poll questions, which are presented in the footnotes to Table 1.) In other words, those questions didn’t just rely on the phrase “single payer,” a phrase most people do not understand.
On the other hand, the three questions that prompted support in the 50-to-58-percent range used the phrase “single-payer” but did not refer to an existing single-payer system or program. The second AP-Yahoo question, for example, merely asked respondents if they considered themselves to be “single-payer supporters.” Fifty-four percent said yes to that question, which was substantially below the 65 percent who indicated in the same AP-Yahoo poll that they supported a system of universal coverage “like Medicare.” These two AP-Yahoo questions taken together suggest that merely using the term “single-payer” and not comparing it to Medicare will cut roughly 10 percentage points off the support level for single-payer.
It might be argued that the second AP-Yahoo question shown in Table 1 produced a relatively low single-payer support rate (54 percent) because it also mentioned the words “taxpayers” and “government.” But that argument doesn’t work. All but one of the other questions that produced support levels of 60-percent or higher also mentioned “government” and “taxes.” The difference is they also mentioned an existing single-payer system or program.
Apples-to-aardvarks comparisons also reduce support for single-payer
The two questions in Table 1 posed by the 2009 Kaiser poll (see question 13, page 8), which showed 58 and 50 percent support for single-payer, reveal another factor that seems to influence poll results – a factor I’ll call the “line-up effect.” The Kaiser poll asked about single-payer as well as a half-dozen other proposals without indicating what effect each proposal would have on costs, the number of uninsured, and freedom to choose one’s doctor, to name just a few of the variables most people would be interested in. By contrast, the polls listed in the 60-percent-or-higher category did not present single-payer in a line-up with other proposals; they simply asked whether respondents would support a single-payer system, or they contrasted single-payer with the current system. The “line-up effect” generated by the Kaiser polls would be minimized or eliminated in a citizen jury experiment because the jury would have plenty of time to inquire about the relative effectiveness of the competing proposals. Respondents to polls don’t have that luxury.
The 2009 Kaiser poll began with this announcement:
Now I’m going to read you some different ways to increase the number of Americans covered by health insurance. As I read each one, please tell me whether you would favor it or oppose it.
Notice the phrase, “different ways to increase the number of Americans covered by health insurance.” It implies the “different ways” have all been shown by research to work, and perhaps to reach roughly similar results.
This question was then followed by a description of eight proposals, including “expanding Medicare to people between the ages of 55 to 64,” “offering tax credits to help people buy private health insurance,” and “requiring all Americans to have health insurance.”
This “line up” method of asking about support for single-payer is by no means fatal, but it does appear to reduce the pro-single-payer response rate by somewhere in the range of 5 to 10 percentage points. The Kaiser question that produced 58 percent support asked about “having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for all.” Because this question did not mention taxes and government, you might think more than 58 percent of Americans would have said they favored this proposal. After all, when other polls that do not put single-payer in a line-up but do compare single-payer to Medicare and do mention “government” and “taxes” (see the upper half of Table 1), more than 60 percent indicate their support. The fact that only 58 percent of Americans responded favorably to this question from Kaiser – a question that does mention Medicare but mentions neither “taxes” nor “government” – begs for an explanation. It is reasonable to hypothesize that the explanation is the “line up” context in which the question was asked.
The second Kaiser question listed in Table 1, the one that produced only 50 percent support, contained a double whammy. Like the first Kaiser question, it used the line-up method; unlike the first question, it failed to compare single-payer with Medicare or another single-payer system. This suggests that the cumulative effect of the line-up method plus failure to compare single-payer to Medicare can diminish support for single-payer by about 15 percent.
Perhaps an analogy will help. Imagine if you were asked to indicate whether you “favored or opposed” six “ways to lose weight,” and the “ways” (“ways” is the noun Kaiser uses) ranged from the truly effective (for example, exercising for half an hour a day) to the barely effective (for example, weight loss pills or drinking more water). Imagine furthermore that the pollster gave you no information at all on the effectiveness of the various “ways” nor on their side effects. It seems likely that many respondents could be lulled into thinking all the “ways” are roughly equivalent in effectiveness and that respondents would, therefore, give less support to the effective methods of weight loss in response to this type of “line up” question than they would if they were simply asked, “Do you support exercise as a means of weight loss?”
Let me offer one more example of the use of the line-up method in a poll about health care reform, this one the July 2009 poll by Time Magazine. Time posed questions about seven different proposals that began with the phrase, “Would you favor or oppose a health care bill that…?” The implication of the phrase “a health care bill” is that members of Congress and experts in general think all of the proposals the respondent is about to hear will ameliorate the health care crisis to some degree, perhaps to the same degree. The single-payer question read:
Would you favor or oppose a health care bill that creates a national single-payer plan similar to Medicare for all, in which the government would provide health care insurance to all Americans?
Forty-nine percent favored single-payer, 46 percent opposed it. Like all the poll questions shown in Table 1 that showed support for single-payer in the 60-to-70-percent range, the Time question mentioned Medicare and “government.” (Oddly, unlike the high-scoring poll questions in Table 1, the Time question didn’t mention “taxes.”) You might think, then, that the Time poll would have produced a level of support for single-payer in the sixties. The fact that it produced only a 49 percent “favor” rating suggests, again, that something about the “line up” format reduces support for single-payer by about 10 percentage points.
To sum up this section: Polls that ask reasonably informative questions about single-payer show that somewhere between 60 and 70 percent of Americans support single-payer. This level of support can be reduced into the 50-to-60 percent range by two methods: Asking about “single-payer” without comparing single-payer to Medicare or the systems of Canada or the UK; and inserting the question about single-payer in a list of a half-dozen other proposals without warning respondents that the non-single-payer proposals, especially incremental proposals like tax credits, will have effects that are quite different from the single-payer proposal.
Two more examples of polls that convey too little information
To explore further the hypothesis that vagueness in poll questions diminishes support for single-payer, consider polls that are even vaguer than the polls in Table 1 that use “single payer” but offer almost no details about it. Let’s examine three polls that did not use the phrase “single payer” and offered no details about how the proposed “government” program would work.
In Part 2 of this series, I described a CBS poll conducted in June and August 2009 which asked:
Do you think the government would do a better or worse job than private insurance companies in providing medical coverage?
This question has the ring of a single-payer question, but it leaves numerous important questions unanswered, including whether the program in question would provide coverage to everyone and whether “provide” means cover people directly or give them subsidies so they can buy coverage from insurance companies.
We saw that when this question was asked in June 2009, 50 percent said “the government” would do a better job, but when this question was asked in late August 2009, only 36 percent said “the government” would do a better job. Does this CBS poll contradict the more precise polls listed in Table 1 that found two-thirds support for single-payer?
The answer is no. The CBS poll conveys so little information about how “the government” would do the “job” of “providing medical coverage” that it isn’t even clear if this question was meant to be about single-payer. In the context of the current debate, Americans are much more likely to think the question refers to the Democrats’ 2009 “reform” bills, which require Americans to buy health insurance from insurance companies, than to single-payer legislation. The sharp drop in support for “the government” in the CBS poll between June and August is evidence that the highly publicized town hall meetings held in August to discuss the Democrats’ bills influenced responses to the poll, which in turn indicates many respondents thought the question was about the Democrats’ legislation, not HR 676 (the single-payer bill introduced in the House of Representatives) or S 703 (the Senate single-payer bill).
We see a similar problem in the following question, contained in both a CBS/New York Times poll and a Harvard School of Public Health poll, conducted over several decades:
Do you favor or oppose national health insurance, which would be financed by tax money, paying for most forms of health care?
Like the phrase “government providing medical coverage” in the CBS poll, the phrase “national health insurance” in this poll could mean government financing of universal coverage through a single-payer system or through a multiple-payer system. If you look at Exhibit 1 on page 35 of this article from Health Affairs, you’ll see that between 1980 and 2000 the percent of respondents saying they favor “national health insurance” ranged between 46 and 66 percent. The vagueness of the phrase was unquestionably a significant reason why support fluctuated so much.
Another way to diminish support for single-payer: Convey inaccurate information
In addition to conveying vague information about single-payer there is, of course, another time-tested method of diminishing support for it, and that is to convey inaccurate information about it. This can be done explicitly and implicitly. It can be done explicitly by, for example, asserting in the question that single-payer systems raise taxes but do not lower premium payments and out-of-pocket costs. We have already seen one example of how reducing support for single-payer with inaccurate information can be done implicitly – by inserting the single-payer question into the middle of several other proposals, including incremental proposals such as tax credits for small employers, without warning respondents that the proposals have very different benefits and side effects.
Since 2001, the Gallup poll has been asking this explicitly misleading question (apparently each November):
Which of the following approaches for providing health care in the United States would you prefer: replacing the current health care system with a new government-run health care system, or maintaining the current system based mostly on private health insurance? (emphasis added)
“Government-run health care system” has garnered somewhere between 32 and 41 percent support since 2001 (while keeping the “current system” has attracted the support of 48 to 63 percent). But this poll is so biased it is irrelevant to the current debate. The problem here is the use of the phrase “health care” three times instead of “health insurance.”
The government does not “run health care” under single-payer systems (or any other system currently under debate in the US, for that matter). Under single-payer systems, clinics, hospitals, and makers of drugs and equipment that are privately owned today would remain in private hands. What the government will “run” in a Medicare-for-all system is health insurance, not health care. The latter phrasing conjures up nightmares of a gigantic government HMO in which the federal HMO owns all the clinics and hospitals and government bureaucrats decide whether you may have the surgery you and your doctor think you need or whether you must take Lipitor when your doctor prescribed Crestor.
I will discuss another example of a poll that delivers explicit misinformation in Part 5 when I discuss the “research” Celinda Lake did for the “option” movement.
The Bermuda Triangle
Finally, there is the occasional outlier poll that produces very low favorability ratings for single-payer about which I can only offer a plausible hypothesis. The August 7-8, 2009 Rasmussen Poll (not shown in Table 1) is an example. The poll asked:
Do you favor or oppose a single payer health care system where the federal government provides coverage for everyone?
We would expect this poll to produce “favor” responses below the 60-percent level because it offers so little information about what a single-payer is (it doesn’t mention Medicare or the Canadian or British systems, and offers no other details). But Rasmussen reported that only 32 percent supported single-payer while 57 percent opposed it. This question was not asked as part of a “line up,” so the line-up explanation doesn’t help us here. The two explanations that occur to me are sloppiness and deliberate manipulation of the process (for example, sampling a lot more conservatives than liberals). That possibility has occurred to others as well. Rasmussen’s non-electoral polls seem to show more support for conservative positions than other polls.
We have now reviewed three categories of polls that correspond roughly to support levels of 60 to 70 percent, 50 to 60 percent, and below 50 percent. Polls that produce greater-than-60-percent levels of support for single payer not only use the phrase “single-payer” but compare the concept to an existing single-payer program, typically Medicare. Polls showing 50 to 60 percent support inquire about “single payer” without comparing the concept to Medicare or to the single-payer systems of other countries or they pose the question about single-payer in a line-up context. Polls that seem to ask about single-payer and which show less than 50 percent support use phrasing that is so vague respondents cannot know whether the program being asked about is a single-payer and, if so, how it would work.
We saw in Part 2 of this series that two citizen juries conducted in the 1990s produced landslide votes for single-payer – votes equal to roughly 60 to 80 percent of all the participating “jurors.” These lengthy “jury” experiments are far more reliable than any poll could possibly be. And yet some polls confirm the “jury” experiments and some don’t. If we ask why, the answer is the polls that show support in at least the 60-to-70-percent range use the phrase “single payer” and give respondents concrete examples of single-payer programs.
If we couple the “jury” experiments with the polling data reviewed in this part, we see a pattern: The more people know about single-payer, the more likely they are to support it. We see this pattern when we compare the “jury” results with poll results, and we see it when we compare polls that show high levels of support for single-payer with those that don’t.
Stay tuned for Part 4: “Jacob Hacker’s ambiguous polls”
Table 2: Sources
Harvard/Harris poll: Robert J. Blendon et al., “Views on health care: Public opinion in three nations,” Health Affairs, Spring 1989;8(1)149-157.
Los Angeles Times poll: “Health Care in the United States,” Poll no. 212, Storrs, Conn.: Roper Center for Public Opinion Research, March 1990, cited in Robert J. Blendon et al., “Satisfaction with health systems in ten nations,” Health Affairs, Summer 1990;9(2): 185-192. Actual wording of the question is available at American Public Opinion Index, 1990, p. 649.
Wall Street Journal-NBC poll: Michael McQueen, “Voters, sick of the current health –care systems, want federal government to prescribe remedy,” Wall Street Journal, June 28, 1991, A4 (question available here).
New England Journal of Medicine poll: Steven R. Simon et al., “Views of managed care: A survey of students, residents, faculty, and deans of medical schools in the United States,” New England Journal of Medicine 1999; 340:928-936, 929.
Washington Post-ABC News Poll: Health Care, October 20, 2003.
Archives of Internal Medicine poll: Danny McCormick et al., “Single-payer national health insurance: Physicians’ views,” Archives of Internal Medicine 2004;164:300-304.
Civil Society Institute poll: Opinion Research Corporation, Americans and Health Care Reform: How Access and Affordability are Shaping Views, September 15, 2004.
Minnesota Medicine poll: Joel Albers et al, “Single-payer, health savings accounts, or managed care? Minnesota physicians’ perspectives,” Minnesota Medicine, February 2007:36-40.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Harry Reid: Democrats reach ‘broad agreement’
By Carrie Budoff Brown & Patrick O’Connor
December 9, 2009
Senate Democrats have reached a “broad agreement” on a health reform bill, Majority Leader Harry Reid said Tuesday night — a plan that would replace the public option in the current Senate bill with a new national insurance plan offered by private insurers, and a chance for older Americans to “buy in” to Medicare.
To win over liberals disappointed at losing the public option, Democrats would allow older Americans starting at age 55 to buy into Medicare, the popular program for the aged. The Medicare expansion would be a significant victory for Democrats, who spent years pushing for it. The proposal would in effect create a public health insurance option for older Americans, since Medicare is government-funded and government-run.
The most efficient, most effective, and least expensive method of providing reasonably comprehensive health care for everyone would be to replace all current public and private financing programs with a single, improved Medicare program that covered absolutely everyone. Some have suggested that we can do this incrementally, with the first step being to allow individuals 55 and over to buy into Medicare. Is this a good idea?
Harvard professor Steffie Woolhandler provides us with some insight: “Lowering the eligibility age for Medicare to 55 only works if it is mandatory. Otherwise it becomes the place where all the sickest patients get dumped. That might be okay for the sick people since Medicare is often better and more secure than private coverage, but it would drive total health care costs (and premiums) up, not down.”
The current Medicare risk pool is composed of seniors with a high rate of chronic disease and with the expenses of end-of-life care, plus younger individuals with long-term disabilities. Since this is a very high cost population, the prorated premiums would be unaffordable for most individuals 55 thru 64. A separate risk pool would have to be established that would be limited to this age bracket. Unfortunately, 55 thru 64 is still the most expensive age sector of all individuals under 65 and so premiums would still be unaffordable for most, especially after you add in the impact of adverse selection as Steffie Woolhandler has described.
Suppose that a Medicare buy-in for those over 55 were to be established, and that higher government subsidies were provided to cover the higher costs, then what do you have? You have created a public option. Yet the reason being given for the Medicare buy-in is that it is a trade-off to get the progressives to agree to abandoning the public option.
So the agreement seems to be to eliminate the public option from consideration by establishing a public option. But is the proposal a public option that would allow everyone the opportunity to buy into Medicare? Apparently not. After all, this is Congress at work.
Although details have not been released, it appears that this Medicare buy-in would be limited by the same rules already proposed for the public option. Individuals who already are eligible for employer-sponsored coverage, Medicare, or Medicaid would not be eligible to participate in the insurance exchange, yet the Medicare buy-in would not be available outside of the exchange (except perhaps during a transition before the exchange is established). Thus the net effect of this buy-in is to further limit the public option only to those 55 and over who meet all other qualifications for the exchange – a ratcheted-down version of the public option.
An elective buy-in for Medicare will only add to the perpetuation of inequities, fragmentation, administrative inefficiencies, inadequate fiscal supervision and other deficiencies that plague our health care financing system. Adding to our dysfunctional system only compounds the dysfunction. We need to replace the system with an efficient single payer model.
Could we do that in incremental steps by first moving absolutely everyone over 55 into our existing Medicare program? Yes, but why would we do that? There would be complex transitional issues in changing this sector from a revenue source for Medicare into both a revenue source and an expense as they become beneficiaries of the program. Another increment could be MediKids for all children, though that would involve other transitional issues. Then how soon would we phase in everyone else, with yet still more transitional issues?
Incremental steps increase the complexities and costs of the transition while delaying access for many who already have impaired access and financial burdens caused by our dysfunctional system.
A single, disruptive transition would actually be more efficient administratively, while lowering transitional costs. Much more important, a single transition would ensure that no person would have to wait any longer to access the care that he or she needs merely because of an inability to pay for that care.
If we advocate for less than we need, we’ll end up with cheap chits that will eventually be traded away, and then what are we left with?
Questioning a $30,000-a-Month Cancer Drug
By Andrew Pollack
The New York Times
December 4, 2009
A newly approved chemotherapy drug will cost about $30,000 a month, a sign that the prices of cancer medicines are continuing to rise despite growing concern about health care costs.
Critics, including many oncologists, say that patients and the health system cannot afford to pay huge prices for drugs that, on average, provide only a few extra months of life at best.
And Folotyn (made by Allos Therapeutics) has not even been shown to prolong lives — only to shrink tumors. The drug was approved by the Food and Drug Administration in late September as a treatment for peripheral T-cell lymphoma, a rare and usually aggressive blood cancer that strikes an estimated 5,600 Americans each year.
(James V. Caruso, the chief commercial officer for Allos) said the price of Folotyn was not out of line with that of other drugs for rare cancers. Patients, moreover, are likely to use the drug for only a couple of months because the tumor worsens so quickly, he said.
In a note to clients in October, Joshua Schimmer, an analyst at Leerink Swann, estimated that a typical treatment would last 3.5 months and cost $126,000, or about $36,000 a month.
Prescribing Information for Folotyn (pralatrexate injection)
Allos Therapeutics, Inc.
Issued: September 2009
Indications and Usage:
Folotyn is indicated for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL). This indication is based on overall response rate. Clinical benefit such as improvement in progression free survival or overall survival has not been demonstrated.
Adverse reactions (list includes only those events occurring in 10 percent or more of patients treated):
Liver function test abnormal
Pain in extremity
Upper respiratory tract infection
Percent of patients experiencing any adverse event: 100 percent
Forty-four percent of patients (n = 49) experienced a serious adverse event while on study or within 30 days after their last dose of Folotyn.
Patient Protection and Affordable Care Act (Amendment in Senate)
The Library of Congress, THOMAS
Title VII – Improving access to innovative medical therapies
Sec. 7002, (a), (2), (k)
(7) Exclusivity for reference product
(A) Effective date of biosimilar application approval – Approval of an application under this subsection may not be made effective by the Secretary until the date that is 12 years after the date on which the reference product was first licensed under subsection (a).
Fotolyn is a new miracle drug brought to us by our highly revered pharmaceutical industry. This new drug has no demonstrated clinical benefit, though all patients have adverse reactions, almost half of them serious – including death.
In an astonishing moment of candor, James Caruso, chief commercial officer for Allos, provided reassurance that the very high monthly cost of Fotolyn would not be protracted since the tumor worsens so quickly.
What makes this drug a miracle only the investment community can understand. Desperate patients will spend an average of $126,000 for this worthless drug. On Wall Street that’s a miracle, but within the health policy community, that’s a tragedy.
You can be assured that, in crafting health care reform, Congress has responded to the very high prices of newer patented therapeutic agents, but in a perverse way. Recognizing the great potential of genetically-engineered biologics, Congress has included in the legislation an unprecedented 12 year exclusivity, protecting the firms from competition of biosimilar products.
Maybe the biotech firms will be able to parley this into seven-figure treatment programs for the desperately ill. The soak-the-sick policies may not work for patients, but they certainly work well for Wall Street. And doesn’t that seem to be where Congress’s loyalties lie these days?
On December 3, Dr. Chris Stack joined a group of over 30 health care activists to protest at the office of Sen. Evan Bayh. The group spoke with Sen. Bayh’s regional director, Andrew Hogan, who promised to pass along the group’s demands to the senator. Dr. Stack is a retired orthopedic surgeon who has been an active member of PNHP since 2003.
Two-thirds of Americans support Medicare-for-all (#2 of 6)
Citizen juries demonstrate massive support for single-payer
By Kip Sullivan, JD
“They contradicted both beltway and public opinion polls. The whole damn world seems to think the Clinton plan is the way to go. Yet they like the single-payer system, which isn’t even getting considered in Washington.”
That was how the president of the Jefferson Center characterized the outcome of a five-day “citizen jury” experiment in which 24 “jurors” listened to and questioned 30 experts on health care reform. (Patrick Howe, “‘Citizens jury’ supports Wellstone’s health care proposal over Clinton plan,” Minneapolis Star Tribune, October 15, 1993, 10A.) Of those 30 experts, only one, Senator Paul Wellstone (D-MN), spoke in favor of single-payer. (Gail Shearer of Consumers Union, which had endorsed single-payer by 1993, was one of the 30 experts to speak to the jury, but it is not clear from the Jefferson Center record that she spoke in favor of single-payer.)
The jury heard expert testimony for and against all three of the major types of health care reform legislation that have been promoted in the US over the last four decades. Senator Wellstone presented the case for his single-payer bill, numerous speakers made the case for Bill Clinton’s managed competition bill (a bill based on competition between insurance companies that use managed-care cost-control techniques), and numerous speakers made the case for what later came to be called “consumer-driven” health insurance policies (competition between insurance companies that sell policies with deductibles on the order of $2,000 for individuals and $5,000 for families).
The jury voted by massive majorities to reject the market-based proposals – managed competition and high-deductible policies – and, by a landslide majority (17 out of 24, or 71 percent), to endorse Wellstone’s single-payer bill. At the time the Jefferson Center report noted only that a majority of jurors voted for single-payer. The actual vote count was reported years later by Barry Casper in his book, Lost in Washington: Finding the Way Back to Democracy in America.
The unbearable lightness of polls
Observers were surprised at the jury’s rejection of the Clinton plan because polls taken at the time the Jefferson Center jury was meeting (the second week of October 1993) were reporting that a majority of the public supported Clinton’s Health Security Act, his “managed competition within a budget” bill that was supposed to create a system of universal health insurance. For example, a Gallup/CNN/USA Today poll (see Exhibit 1 page 10) released on September 24, 1993 showed 59 percent endorsed Clinton’s bill. But just three weeks later, on October 14, 1993, the jury rejected Clinton’s bill by a vote of 19 to 5. Five jurors out of 24 comes to 21 percent, far below the 60-percent level one would have expected based on polls.
The enormous gap between the citizens jury’s vote on Clinton’s bill and contemporary poll results illustrates a well known problem with polls: Although they can produce consistent and accurate results when the question is about something the respondents are familiar with, such as whether they have health insurance, they can produce wildly divergent and inaccurate results when the question is about a complex issue that respondents have had little time to study or even to think about.
Contrast, for example, a 2007 AP-Yahoo poll, which found 65 percent of Americans support a Medicare-for-all system, with a 2009 CBS poll which found only 50 percent think “government” would do a “better job” of providing health insurance than the insurance industry. The AP-Yahoo poll posed this question (the order of the two solutions was reversed from one respondent to the next):
Which comes closest to your view?
The United States should continue the current health insurance system in which most people get their health insurance from private employers, but some people have no insurance;
The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.
Sixty-five percent of respondents chose the second solution – the Medicare-for-all solution – while only 34 percent chose the current system.
Now consider the June 12-16, 2009 CBS poll which asked: “Do you think the government would do a better or worse job than private insurance companies in providing medical coverage?” Fifty percent said “the government” would do a better job versus 34 percent who said “the government” would do a worse job.
Now, just to raise your skepticism about polls another notch, consider this wrinkle. When CBS asked the same question two months later – during August 27-31, 2009 – they found 13 to 14 percent of respondents had changed their minds in favor of the insurance industry. That is, by late August (by which time dozens of tumultuous “town hall” meetings about the Democrats’ health care “reform” legislation had taken place), the percent who thought “the government” would do a better job had fallen to 36 (from 50 percent) while the percent who thought “the government” would do a worse job had risen to 47 (from 34 percent).
How do we make sense of these seemingly contradictory results? Do we trust the late-August CBS poll and say only one-third of Americans support single-payer? Or do we go with the AP-Yahoo poll and say two-thirds support single-payer? Or do we split the difference and say the June CBS poll got it about right – that half of Americans support single-payer?
Fortunately, we are not reduced to rolling dice or drawing straws. We can examine research that uses methods more reliable than those used by the typical poll, notably two citizen jury experiments. And we can examine polls that have produced contradictory results to see if we can find a reason why. I will use the remainder of this paper to report on the two citizen juries. I’ll examine polling data more closely in Part III of this series.
The Jefferson Center’s methodology
The Jefferson Center, a non-profit organization created in 1974 by Ned Crosby, invented the “citizen jury” label and developed the rules for them that are now used around the world, especially in the United Kingdom. These methods include: random selection of jurors; selection of experts and moderation of the discussion in a manner that minimizes bias; recording of the proceedings; a report from the jury indicating votes taken on major issues presented to it and recommendations from the jury; questionnaires for jurors after the jury has completed its work to inquire about their perception of the fairness of the process; and oversight and review by a steering committee to minimize bias.
The 24 jurors who gathered in a Washington, DC hotel on Sunday, October 10, 1993 were randomly selected from a pool of 2000. They included a 23-year-old college student from Colorado, a 27-year-old carpenter from Wisconsin, a 32-year-old janitor from Minnesota, a 44-year-old village clerk from New York, a 46-year-old banker from Indiana, a 51-year-old antique dealer from California, a 59-year-old retired nurse from Louisiana, and a 75-year-old retired insurance agent from Florida. Ten had voted for Clinton in the 1992 election, nine for George H.W. Bush, and five for Ross Perot. Three had no health insurance.
The experts who addressed the jury included three sitting US Senators, two former members of the House of Representatives, and 25 other experts including Gail Wilensky (who was the director of Medicare under the first President Bush and is a member of numerous corporate boards), Ira Magaziner (who directed Hillary Clinton’s health care reform task force), and Ron Pollack (director of Families USA). The discussion was moderated by Kathleen Hall Jamieson, dean of the Annenberg School for Communication at the University of Pennsylvania. Former CBS and NBC TV anchor Roger Mudd was on hand to film a documentary which aired in April 1994.
After five days of listening to and cross-examining the 30 experts (the jury asked the experts more than 500 questions), the jurors refused even to vote on the “managed competition lite” proposal presented by Senator Dave Durenberger (R-MN) and a high-deductible (Medical Savings Account) proposal presented by Senator Don Nickles (R-OK). In other words, the jury rejected the Durenberger and Nickle’s legislation by a vote of 24 to zero. They rejected Clinton’s Health Security Act by a vote of 19 to 5. When they were asked how many supported Sen. Wellstone’s single-payer bill (S. 491), 17 of 24 (71 percent) raised their hands.
Washington Post columnist William Raspberry wrote at the time:
Perhaps most interesting about last week’s verdict is its defiance of inside-the-Beltway wisdom that says a single-payer … plan can’t be passed. These jurors think it can – and ought to be. (William Raspberry, “Citizens jury won over by merits of Wellstone’s single-payer plan,” Washington Post, October 21, 1993, 23A)
I have already noted one reason why observers were surprised by the jury’s votes, namely, polls taken around the time the jury met indicated a majority of the public liked Clinton’s bill. But there was another reason to be surprised: The Jefferson Center created a playing field that was steeply tilted against Wellstone’s single-payer bill.
To begin with, the Center limited the jury to two questions: “Do we need health care reform in America?” and, “Is the Clinton plan the way to get the health care reform we need?” Second, the agenda called for presentations by a team of Republicans and their expert witnesses arguing for Republican proposals, and a team of Democrats and their expert witnesses arguing for Clinton’s Health Security Act. (The Republican team was managed and represented by former Minnesota Congressman Vin Weber; the Democrats were led by Hill and Knowlton lobbyist and former Connecticut Congressman Toby Moffett.) There was no team advocating for single-payer. There was only Wellstone.
But the jury was so attracted to Wellstone’s description of his bill during his initial presentation that they voted 22-0 to invite him back for two more question periods (see page 10 of the Jefferson Center report). No other witness was asked back even once. “In fact,” noted columnist Raspberry, “when the Minnesotan [Wellstone] dropped in at the jury’s farewell dinner Thursday night, he got a standing ovation.”
To sum up: The Jefferson Center’s citizen jury methodology was far more rigorous than any two- or three-sentence poll can be, and yet even the methods used for that jury permitted substantial bias against the single-payer approach. A total of 30 experts spoke to the Jefferson Center jury over five days. Only one of them, Senator Wellstone, made the case for single-payer. Even though the question of whether to support or oppose single-payer was not on the agenda, the jury took the initiative to get more information about it. The jury did not have to do that for any other proposal. Despite these obstacles, the single-payer proposal won by a 71-percent majority.
Minnesota citizen jury endorses single-payer by 79 percent
On October 1, 1996 I was part of another citizen jury project sponsored by the Minneapolis Star Tribune and Twin Cities Public TV which used a methodology similar to the Jefferson Center’s jury and which had a nearly identical outcome. In this case, the jury consisted of 14 randomly selected Minnesotans, only three experts spoke, and the entire event lasted just four hours. I made the case for single-payer (at that time I represented Minnesota Citizens Organized Acting Together), Michael Scandrett (then the director of the Minnesota Council of HMOs) stated the case for managed competition, and a woman who had just left a job with the Minnesota Department of Health to create her own advocacy group for Medical Savings Accounts (MSAs, now referred to as Health Savings Accounts) presented the argument for MSAs.
At the end of four hours, the moderator for the evening (an officer of the Minnesota League of Women Voters) put several questions to the jury for a vote. Her first question asked each juror which proposal they supported. Eight voted for single-payer, three voted for managed competition, one woman split her vote between single-payer and managed competition (she said she wanted the two proposals to be married somehow), no one voted for MSAs, and two of the 14 abstained. If we allocate a half of the vote by the woman who wanted some combination of managed competition and single-payer to each proposal, single-payer’s total was 8.5, or 61 percent of the 14 jurors.
The moderator’s second question asked whether the jurors would support universal coverage under a single-payer system if citizens had to pay $1,000 more in taxes that were offset by $1,000 in reduced premiums and out-of-pocket costs. (This is a conservative estimate of what would happen. It is likely that aggregate premium and out-of-pocket costs would decline more than aggregate taxes would go up under a single-payer system, and very likely that premium and out-of-pocket costs would decline substantially more than taxes would go up for lower- and middle-income Americans.) Eleven said yes to this question, and three abstained. If we treat this latter vote as the definitive vote for single-payer, then it would be accurate to say 79 percent voted for single payer. Finally, the moderator asked if the jury thought Congress had failed to give single-payer a fair hearing. Again, 11 (79 percent) said yes and three said no. (Glenn Howatt, “Canadian-style care starting to look more attractive to panelists,” Minneapolis Star Tribune October 9, 1996, A15)
Stay tuned for Part 3: “Informative polls show two-thirds support for single-payer.”
How health care bills compare to lawmakers’ plan
By Ricardo Alonso-Zaldivar
The Washington Post
December 6, 2009
You should get the same health insurance deal that members of Congress get. That was the gist of President Barack Obama’s message as he tried to drum up enthusiasm for his health care overhaul.
Government workers and members of Congress belong to the nation’s largest employer-sponsored health plan, covering 8 million employees, dependents and retirees.
“We estimate there are about 250,000 federal employees who are uninsured. They’re eligible, but they can’t afford the premiums,” said Jacqueline Simon, policy director for the American Federation of Government Employees.
New Government-Run Health Proposal Eyed
Democrats, in Search of Compromise, Explore Federal Employee Plan as a Model
By Greg Hitt And Janet Adamy
The Wall Street Journal
December 7, 2009
Democrats on both sides of the issue who were assigned by Sen. Reid to find a compromise were nearing agreement on an alternative that would empower the government’s Office of Personnel Management to run a new national health plan, congressional aides said. The office already oversees the federal employee health plan, and administration officials have pointed to it as an example of how the government can successfully run a health-insurance program.
Under the proposal, the office would negotiate terms of the plan with private insurers, and contract with nonprofit entities set up by the private sector to run the program, aides said.
Federal Employees Health Benefits Program (FEHBP)
AmericanFederation of Government Employees
February 9, 2009
FEHBP has both structural and political flaws.
Those who must rely upon FEHBP for health insurance know its flaws well, and consider it anything but a model.
An estimated quarter of a million federal workers and their families are uninsured because FEHBP premiums are unaffordable to them on their modest federal salaries. The continued cost-shifting only increases the ranks of uninsured and underinsured Americans.
Why shouldn’t we all have the same insurance that members of Congress have? They and all other federal employees are covered by the Federal Employees Health Benefits Program (FEHBP), an exchange of private health plans from which they can choose their coverage.
The FEHBP plans share many of the problems found in private health plans marketed to non-government employers. Simply the fact that a quarter million federal workers and their families remain uninsured, though eligible for FEHBP, demonstrates that it is a flawed program that should be rejected as a model for reform.
For those who say that subsidies would make the difference, these federal employees have already been offered subsidies in the form of the federal employer contribution to their premiums, yet they still can’t afford their share of the premium. Besides, because insurance is available through their employment, they would not be eligible for the subsidized exchange plans anyway.
So what is Congress doing? Because of the political impasse over a public plan to be offered as an option to private plans within the insurance exchange, senators are currently advocating for the compromise of a separate exchange of private plans modeled on FEHBP. This model allegedly would satisfy the moderates opposed to the public option because it would be limited to private, non-profit insurers, and allegedly would satisfy the progressives because they could claim that it’s like the government insurance that members of Congress have. Of course there’s nothing government about it.
What is more ridiculous is the structure of this phony public option. It would establish an exchange of private insurance plans within an exchange of private insurance plans with a market of private insurance plans outside of the exchanges. What insurer is going to compete against its successful plans on the open market by offering competing plans in the insurance exchange and then competing with its plans in the exchange by offering plans in the exchange within the exchange?
Besides, how many truly dominant insurers are there? They constitute an oligopoly. Just as they play by their own market rules now, they will continue to do so even if modified by guaranteed issue or whatever.
Ask those 250,000 uninsured federal workers who were promised the coverage that members of Congress have what they think about FEHBP. Then ask them if they would like to have Medicare paid for by equitable taxes they can afford rather than by premiums they can’t afford. Then ask them to march on Congress!
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