Does Ezra Klein really think “managed care didn’t kill anyone”?
by Kip Sullivan, JD

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

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

Exhibit A: Washington Post blogger Ezra Klein

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

Klein actually wrote:

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

What data might this be? Klein offers none.

Instead he offers this sleight-of-hand:

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

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

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

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

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

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

Managed care did great harm

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

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

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

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

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

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

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

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

Managed care did not cause the 1991-1996 inflation lull

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

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

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

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

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

Post-train-wreck debate

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

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

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

CDC/NHIS – uninsured and underinsured

Posted by on Friday, Dec 18, 2009

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.

Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey (NHIS), January – June 2009

by Michael E. Martinez, M.P.H., M.H.S.A., and Robin A. Cohen, Ph.D., Division of Health Interview Statistics, National Center for Health Statistics
Centers for Disease Control and Prevention (CDC)
National Center for Health Statistics (NCHS)

From January to June 2009, 45.4 million persons of all ages (15.1%) were uninsured at the time of interview, 58.4 million (19.4%) had been uninsured for at least part of the year prior to interview, and 31.9 million (10.6%) had been uninsured for more than a year at the time of interview.

From January to June 2009, 60.6% of unemployed adults aged 18-64 years and 21.8% of employed adults in this age group had been uninsured for at least part of the past year. Also, 32.9% of unemployed adults aged 18-64 and 13.3% of employed adults in this age group had been uninsured for more than a year.

Estimates of enrollment in HDHPs, CDHPs

Based on data from the January to June 2009 NHIS, 22.7% of persons under age 65 years with private health insurance were enrolled in a HDHP (high-deductible health plan), including 6.4% who were enrolled in a CDHP (consumer-directed health plan) and 16.4 % who were enrolled in a HDHP without a health savings account (HSA). Enrollment in HDHPs increased from 17.5% in 2007 to 22.7% in the first 6 months of 2009. There was a significant increase in enrollment in HDHPs without HSAs and in CDHPs between 2007 (when NHIS started collecting this information) and June 2009.

Based on data from the first 6 months of 2009, among persons under age 65 with private health insurance, 20.3% with employer-based coverage were enrolled in a HDHP, compared with 48.7% of those with a private plan that was directly purchased or obtained through means other than an employer. The percentage of persons covered by employer-based private plans that are HDHPs increased from 15.6% in 2007 to 20.3% in the first 6 months of 2009. The percentage of persons covered by directly purchased private health plans that are HDHPs increased from 39.2% in 2007 to 48.7% in the first 6 months of 2009. HDHPs constitute a growing share of both employment-based and directly purchased health plans.

One-fifth of the nation has been uninsured for at least a part of the past year. What makes that number even more alarming is that, at the beginning of the reform process, President Obama and the Congress decided, in deference to the private insurance industry, that they wouldn’t even begin to try to insure everyone. Instead they decided to include just those who would fit in under under their model that is designed to nurture the private insurance industry.

Still even more alarming is the insurance coverage that they propose. The standard policies for middle-income Americans will have an actuarial value of 60% to 70%, which provides much less financial protection than did more traditional employer-sponsored plans. But look what is already happening. Employers are shifting more workers to high-deductible health plans (HDHPs), and in the individual insurance market, almost half of the plans purchased are HDHPs. Furthermore, almost three-fourths of these do not have the backup of a health savings account (HSA).

Except for relatively wealthy individuals, these HDHPs are underinsurance products. They do not provide adequate financial security for those who do develop health care needs.

So President Obama and the Congress are bailing on not only on the tens of millions who will remain uninsured, but also the ever growing number of us who will be underinsured, whether through individual or employer-sponsored plans.

The status quo is unacceptable, but so is this legislation. Dump it and move on immediately with reform that protects the financial well-being of absolutely everyone who needs medical care.

The following are comments by Dr. Walter Tsou, former Philadelphia Health Commissioner on yesterday’s Pennsylvania Senate Banking and Insurance Committee hearing on the state single-payer bill, SB 400.

My overall impression was this was an enormously successful and impressive showing for Pennsylvania state single payer. Yes, I may be biased, but our four panelists did a superb job in explaining the Family and Business Health Security Act. To explain why I say this, consider the concluding remarks of Senator Don White, Republican Chair of the Senate Banking and Insurance Committee. First, Senator White offered that “there were those who said I should not have this hearing” — a clear rebuke of the fearful during this time of healthcare and economic crisis. Second, whereas in his opening comments he downplayed expectations for the hearing as a “fact-finding session only,” by the end, his praise of the Single Payer presenters was so “positive,” he declared that this opening act was just the beginning of a series of hearings on this most important topic.

The hearing began with Senator White, a former insurance broker, welcoming everyone and inviting Senator Jim Ferlo, the lead sponsor of SB 400, to present some opening thoughts. Ferlo explained the need to look at different approaches rather than be tied to the usual failed insurance model. Among other attributes, he said that the state Single Payer plan would free employers from the onerous burden of skyrocketing health insurance costs by, instead, providing healthcare for everyone at far less cost.

Chuck Pennacchio, Executive Director of Healthcare for all PA spoke next and further explained the particulars of the state-level, Single Payer approach, and how it represents values we can all embrace: freedom, choice, fiscal conservatism, personal responsibility, modeling solutions, constitutional federalism, fair-share taxation, efficiency, transparency, accountability, jobs creation, bureaucratic streamlining, investment and reinvestment, coordinated and comprehensive care, reduced rationing, restored patient-provider relationship, healthy outcomes, tort remedy, end bankruptcy fears, healthcare education, “medical home” data base, and more.

Patricia Eakin, RN from Philadelphia explained that she was a nurse in one of the busiest ERs in Pennsylvania at Temple and that she sees the problems of the lack of insurance on a daily basis. She gave some examples of the problems faced by people who have lack insurance. She noted how her hospital was losing money because they had to spend limited resources on billing personnel, and had to absorb, and/or pass along, financial losses on people without insurance or on Medicaid.

Dwight Michaels, MD, a Republican, and family practice doctor from Gettysburg, spoke about how his experience with private insurance bureaucrats had driven him to support the Single Payer Solution. He said it is increasingly difficult to practice medicine because his five-person practice struggles daily with 20 different insurance plans, all with different rules. This bureaucratic nightmare makes it impossible to spend quality time with his patients because he is forced to justify more and more of his procedures with the insurance carriers. Dr. Michaels’ testimony was a vivid description of the life of a family doctor in a dysfunctional system.

David Steil, a former Republican state legislator and head of a small manufacturing business was another inspired choice. Not only did he know all of the Senators but, as a creative-thinking lawmaker, he broke the stereotype that all Single Payer supporters are lefties. Mr. Steil spoke about how he tries to run a business, but the cost and hassle of health insurance has made his company more vulnerable in an international market where his non-American competitors have far cheaper health costs.

I think this panel worked extremely well. Not only were they excellent speakers, but they spoke from real world experiences, not as paid lobbyists. And two were Republicans which was an added bonus. The committee had many questions, but none were nasty and all seemed genuinely interested in the real world experiences of the panelists. And the room was packed with 90% supporters of SB 400. I don’t think this was lost on the committee.

The opposing panel were all known lobbyists for their respective interest groups. They gave the usual refrain of condemning single payer.

NFIB speaker – he simply declared that small businesses don’t want Single Payer, but admitted that healthcare costs are the number one concern of businesses. They want the same outcomes that only Single Payer provides. But since that involves “government bureaucracy,” it cannot possibly work.

PA Medical Society – wants tort reform but not Single Payer because it would be too powerful in controlling reimbursements (and costs).

Capitol Blue Cross – gave a confusing talk about the problems with the Washington federal bill and then simply concluded that SB 400 is just like the Washington bill and should be rejected. Of course, nothing in the federal bill even resembles Single Payer, which is why it is so unpopular.

Hospital Association of PA – opposes any government controls generically. Gave a knee-jerk opposition to Single Payer.

Insurance Federation of PA –  same as the hospitals. They oppose Single Payer as “monopolistic” — working from the assumption that the 35-cents-on-the-healthcare-dollar insurance “middle man” is indispensable, and that a little more regulation and industry “innovation” will solve cost issues.

There was not much time for questions but, frankly, they were special interest lobbyists and not a very interesting opposing panel. If this was a debate, the clear winners were the Single Payer SB 400 panel who did a great service in advancing state-level Single Payer today.

Sen. Sanders’ floor speech on his single payer amendment

Posted by on Thursday, Dec 17, 2009

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.

United States Senate
December 16, 2009

The reading of the Sanders single payer amendment continues in its third hour…

Senate President: The Senator from Vermont.

Sen. Bernie Sanders: I withdraw my amendment.

Voice off camera (believed to be Sen. Tom Coburn): Regular order, Mr. President.

Senate President: The Senator has that right. The amendment is withdrawn.

Sen. Sanders: Mr. President. Pursuant to the thirty minutes…

Senate President: Under the previous order, the Senator from Vermont is recognized for thirty minutes.

Sen. Sanders: Mr. President, let me begin, not by talking about my amendment, but by talking about Republican action right here on the floor of the Senate. Everybody in this country understands that our nation faces a significant number of major crises, whether it’s the disintegration of our health care system, the fact that seventeen percent of our people are unemployed or underemployed, one out of four of our children are living on food stamps, we’ve got two wars, we’ve got global warming, we have a twelve trillion dollar national debt, and the best the Republicans can do is try to bring the United States government to a halt by forcing a reading of a seven hundred page amendment. That is an outrage! People can have honest disagreements, but in this moment of crisis it is wrong to bring the United States government to a halt.

Now, Mr. President, I am very disturbed that I am unable to bring the amendment that I wanted to bring to the floor of the Senate dealing with a Medicare for all single payer program…

… I was more than aware and very proud that this amendment would have been the first time in American history that a Medicare for all single payer bill was brought before a floor of Congress.

C-SPAN video of Sen. Sanders remarks (36 minutes):

Yesterday’s Quote of the Day message left off as the reading of the the Sanders amendment to the Senate health reform bill continued. It was suggested that this abuse of process and lack of civility on the part of Sen. Coburn and the Republican leadership be used as a teaching moment. That moment is here. The video of this Senate floor speech by Sen. Sanders should be shared with others who believe that everyone in our nation should have the health care that they need without having to face financial hardship.

Sen. Coburn demands a reading of Sen. Sanders’ single payer amendment

Posted by on Wednesday, Dec 16, 2009

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.

United States Senate
December 16, 2009

SA 2837. Mr. SANDERS (for himself, Mr. BURRIS, and Mr. BROWN) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN) to the bill H.R. 35

Beginning on page 1, strike line 6 and all the follows to the end and insert the following:

(b) Table of Contents.–The table of contents of this Act is as follows:


Full amendment (366 pages):

The reading of the amendment (live now – Dec. 16):

Today’s message was to have been composed after the introduction of and action on Sen. Bernie Sanders’ (I-VT) single payer amendment to the Senate health care reform bill. His amendment would replace the body of the entire bill with a single payer bill.

When Sen. Sanders made the usual request that the reading of the amendment be waived, Sen. Tom Coburn (R-OK) objected and demanded that the entire amendment be read under rules of regular order.

After one hour, 27 of the 366 pages have been read (or 767 pages in the GPO format). At that rate the reading should be completed at about 1:00 AM tomorrow.

Sen. Coburn is a physician. The Oath of Hippocrates states, “I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.” As a United States Senator involved in a legislative process that should bring benefit to all patients in the nation, this oath should be sacrosanct. Apparently Sen. Coburn is determined to embellish his reputation as Dr. No, quite smug in carrying out his deleterious and mischievous acts.

Might the nation ask why a bill is so important that it must be read in its entirety? Maybe this a teaching moment that we can use to shift the dialogue from deceptive partisan rhetoric into a rational discussion of health policy science. The general public might be astonished to learn that we actually can provide high quality care to everyone at a price we can afford.

At least they can no longer claim that we can’t pass a bill that hasn’t been read.

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

Should polls matter?
By Kip Sullivan, JD

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

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

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

Fixing the “facts” around the policy

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

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

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

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

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

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

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

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

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

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

Why not?

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

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

The political use of polls

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

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

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

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

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

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

The authors remarked:

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

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

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

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

Single payer is the only solution

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

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

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

Concluding thoughts on this series

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

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

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

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

Sheils and Haught analyze the House and Senate bills

Posted by on Tuesday, Dec 15, 2009

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.

Comparing the Cost and Coverage Impacts of the House and Senate Leadership Health Reform Bills: Long Term Costs for Governments, Employers, Families and Providers

Prepared for: The Peter G. Peterson Foundation

By John Sheils and Randy Haught
The Lewin Group
December 7, 2009

Impact on National Health Spending

Both bills would result in an increase in administrative costs. These include the cost of administering private insurance to newly covered people, the cost of administering coverage under Medicaid and the cost of processing eligibility for premium subsidies under the bill.

Both bills would result in a substantial growth in national health expenditures. Total health spending over the 2010 through 2029 period would increase by $781 billion under the Senate bill and $955 billion under the House bill.

What is health care reform going to cost us? To help answer this question, numerous reports have been generated by the Congressional Budget Office (CBO), the Office of Management and Budget (OMB), the Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS), the Council of Economic Advisers (CEA), private foundations, and numerous consulting firms representing the private insurance industry.

Although politicians are using sections of these reports selectively to advance their own agendas, if you read all of the reports you cannot escape the conclusion that the measures designed to slow the growth in health care costs do not begin to offset the anticipated increases in spending. Further, they show that an unacceptable number of individuals will remain amongst the ranks of the uninsured.

This new, highly credible report (credible in spite of ownership by UnitedHealth) by John Sheils and Randy Haught draws the same conclusions. National health expenditures will increase over the amounts projected were there no reform, and about 20 million people will still be uninsured.

One comparatively small number in this report is that administrative costs will increase by about $87 billion in the next decade under either the Senate or the House bill. But this number has much greater significance than the amount would suggest. Not only is this an additional cost, it also adds on to the $4,000 billion in administrative waste that we could recover in the next decade if we merely changed to a single payer system of financing health care. That would free up enough funds to cover our nation’s unmet health care needs.

The following letter to the editor by Dr. Howard Green of Florida was sent to the New England Journal of Medicine in early November. It had not yet been published as of the Dec. 10 issue.

The New England Journal of Medicine (NEJM) has had a decades-old policy of financial disclosure by authors of editorials in order to “prevent financial interests from infringing on the editorial content of the Journal.”

This policy was grossly violated when the editors of the NEJM recently chose to publish an opinion piece by Senator Max Baucus titled “Doctors, Patients, and the Need for Health Care Reform” (Vol. 361:1817-1819, Nov. 5, 2009, No. 19) that included a statement by the author that he had no financial interests to disclose.

In the past year alone, Sen. Baucus has received payments from drug and health insurance companies many times in excess of the $10,000 limit which the Journal recognizes as significant to alter an author’s credibility. By failing to disclose those contributions to Journal readers, Sen. Baucus and the editors of the NEJM have violated their own code of ethics and disclosure meant to support the veracity of opinions and data presented in their journal.

Disclosure of the senator’s directly or indirectly received payments from health insurance and pharmaceutical companies would help readers understand why Sen. Baucus continues to support a government-subsidized, high-overhead, low-outcome private insurance industry operating parallel to and within Medicare insurance.

Disclosure of the senator’s receipt of such “contributions” from the health care sector might demonstrate why he supports a private health insurance industry that siphons away, via administrative overhead, hundreds of billions of dollars annually from physician subscribers to the NEJM, patients, clinics, therapists, and pharmacies.

In addition to failing to disclose in the NEJM the monies he has received from pharmaceutical and health insurance companies, Sen. Baucus failed to inform readers of his personal and his Senate Finance Committee’s continued support for (or acquiescence to) the following policies:

* A federal exemption for private health insurance companies from antitrust regulations.

* A prohibition on Medicare insurance establishing a drug formulary through competitive bidding.

* No federal grants to develop a single EMR and billing system for physicians, hospitals and therapists which would reveal clinical, preventative and surgical outcomes. Outcome revelations would crush the health insurance companies, and allow for free-market competition among doctors and hospitals based on quality and efficiency.

* Protection of private health insurance companies from medical malpractice lawsuits via federal ERISA laws.

* Part D taxpayer subsidies to health insurance and drug corporations.

* Medicare Advantage taxpayer subsidies to health insurance companies.

* Reckless and negligent medical rationing by private health insurance companies via their non-physician employees.

* A government ban on collective bargaining by physicians.

* An inability of Medicare to enlarge its limited risk pool beyond that of the oldest, sickest and most physically disabled citizens of our nation.

* Personal bankruptcies due to a medical illness.

* No real change in malpractice reform. Real malpractice reform would allow internists and family practitioners to fulfill their role as primary care physicians efficiently and productively, tackling dynamic illnesses without prematurely referring their sicker patients to expensive specialists without medical benefit.

By allowing Sen. Baucus to express his opinion without a comprehensive disclosure of the large sums he has received from health insurance and pharmaceutical companies or of his continued support of current health care policies, the editors of the NEJM have surrendered their objective status as an advocate of integrity in research and patient care.


Howard A. Green, M.D., FACP, FAAD, FACMS

Reason’s Matt Welch on French health care

Posted by on Monday, Dec 14, 2009

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.

Why I Prefer French Health Care

The U.S. system’s deep flaws make socialism more tempting

By Matt Welch
January 2010

By now I’m accustomed to being the only person in any given room with my particular set of cockamamie politics. But even within the more familiar confines of the libertarian movement, I am an awkward outlier on the topic of the day (and the topic of this issue of reason): health care.

To put it plainly, when free marketers warn that Democratic health care initiatives will make us more “like France,” a big part of me says, “I wish.” It’s not that I think it’s either feasible or advisable for the United States to adopt a single-payer, government-dominated system. But it’s instructive to confront the comparative advantages of one socialist system abroad to sharpen the arguments for more capitalism at home.

For a dozen years now I’ve led a dual life, spending more than 90 percent of my time and money in the U.S. while receiving 90 percent of my health care in my wife’s native France. On a personal level the comparison is no contest: I’ll take the French experience any day. ObamaCare opponents often warn that a new system will lead to long waiting times, mountains of paperwork, and less choice among doctors. Yet on all three of those counts the French system is significantly better, not worse, than what the U.S. has now.

What’s more, none of these anecdotes scratches the surface of France’s chief advantage, and the main reason socialized medicine remains a perennial temptation in this country: In France, you are covered, period. It doesn’t depend on your job, it doesn’t depend on a health maintenance organization, and it doesn’t depend on whether you filled out the paperwork right. Those who (like me) oppose ObamaCare, need to understand (also like me, unfortunately) what it’s like to be serially rejected by insurance companies even though you’re perfectly healthy. It’s an enraging, anxiety-inducing, indelible experience, one that both softens the intellectual ground for increased government intervention and produces active resentment toward anyone who argues that the U.S. has “the best health care in the world.”

Don’t even get me started on the Kafkaesque ordeal of switching jobs without taking any time off, yet going uncovered by anything except COBRA for nearly two months even though both employers used the same health insurance provider. That incident alone cost me thousands of dollars I wouldn’t have paid if I had controlled my own insurance policy.

I’ve now reached the age where I will better appreciate the premium skill level of American doctors and their high-quality equipment and techniques. And in a very real way my family has voted with its feet when it comes to choosing between the two countries. One of France’s worst problems is the rigidity and expense that comes with an extensive welfare state.

But as you look at the health care solutions discussed in this issue, ask yourself an honest question: Are we better off today, in terms of health policy, than we would have been had we acknowledged more loudly 15 years ago that the status quo is quite awful for a large number of Americans? Would we have been better off focusing less on waiting times in Britain, and more on waiting times in the USA? It’s a question I plan to ask my doctor this Christmas. In French.

(Matt Welch is Reason’s editor in chief.)

Reason magazine is a publication of Reason Foundation, a libertarian organization advancing “free minds and free markets.” In this refreshing moment of candor, Reason’s editor in chief, Matt Welch, does not allow libertarian ideology to cloud the truth about the contrasts between our health care system in the United States and France’s system of social insurance.

He has not abandoned his libertarian ideology in that he seems to reject a single payer system for the United States, while suggesting that France’s “socialist system” can “sharpen the arguments for more capitalism at home.” Yet when he describes the superiority of the French system he is describing attributes of social insurance and not free market capitalism. Including these favorable attributes in the U.S. capitalist system would be impossible without significantly expanding the government role in health care.

He states the he opposes “ObamaCare,” yet for what reason? Although he may be wishing that a capitalistic free market in private health plans would accomplish what France’s social insurance program does, he provides evidence of the opposite. His opposition to the current proposal before Congress seems to be for the same reason that we oppose it. It falls far short of the goals of social insurance. It will not be universal, comprehensive, affordable, equitably funded, adequately risk-adjusted, efficiently administered, nor would it apply the principles of social solidarity that make all other systems more efficient and effective than ours.

Under the proposal, most of our health care system remains the same, with little fundamental change in either employer-sponsored coverage or in our public programs such as Medicare and Medicaid. One advantage for those who “can keep the insurance they have” was to have been removal of the cap on yearly medical costs, but even this promise seems to have been abandoned. Although reform will nominally provide coverage for a portion of the uninsured (falling far short of the goal of universality), it will compound the affordability problem for middle-income Americans though inadequate controls on cost escalation, higher taxes, and higher premiums and out-of-pocket expenses (the opposite of what we were promised).

The nation should listen when a prominent libertarian extolls the virtues of social insurance. Once we accept the principle of social insurance, then we can have a more rational debate over whether we want that to be a single-payer Medicare-type program or a European-style social insurance program using using private plans that are so tightly regulated that they almost function as a single payer system. Though PNHP will continue to advocate for the golden standard of a single payer system, that is the debate that we should be having.

Regardless, we need to dump the current proposal and immediately move on with a reform process that will establish a bona fide social insurance program within the United States. Otherwise Matt Welch will have to keep outsourcing his personal medical care to France.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As Lake put it:

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

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

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

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

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

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

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

Celinda Lake’s poll

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

The poll asked this question:

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

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

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

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

Here are four biases Lake introduced into her poll:

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

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

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

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

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

Invoking the ends to justify the means

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

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

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

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

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

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

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

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

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