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.

http://www.pgpf.org/resources/lewin-senate-house-comparison.pdf

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.

Sincerely,

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
Reason
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.)

http://reason.com/archives/2009/12/07/why-prefer-french-health-care

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?”

Fightin’ The Blues

Posted by on Sunday, Dec 13, 2009

On a cold and rainy December 2, while the Senate in Washington was slogging along debating health reform, a remnant troupe of public-option supporting Organizing for America stalwarts stood outside the corporate headquarters of WellPoint, Inc. in the center of downtown Indianapolis.  Minutes before their demonstration started, three single payer activists slipped in and out of the WellPoint office dropping off a shareholder resolution for next May’s annual meeting.

WellPoint, also known as Anthem or Blue Cross, is the perverted spawn of what was once a charitable venture known as Blue Cross/Blue Shield of Indiana.  From the 40’s up into the 90’s Blue Cross of Indiana was like all the other Blues around the country, non-profit with a charitable mission.  Its board of directors included physicians, hospital administrators, labor and community leaders, and it existed to serve the needs of patients.  But the healthcare market had become increasingly cutthroat, and in the aftermath of the Clinton Health Plan’s crash and burn, there was a huge consolidation in the industry.  Doctors went from solo or small group practices into larger and larger groups.  Hospitals that had been independent since their founding merged and national chains of for-profit hospitals grew powerful and predatory.

The most significant consolidation of all happened in the insurance industry, yet it is the least understood and appreciated.  Health insurance was once predominately state or regional non-profit Blue Cross plans or other regional non-profits, and a few national for-profits.  Now there are nine major national health insurers dominating the country.  They are for-profit, beholden not to their customers but to their shareholders.  Like most consolidated industries, they don’t compete head to head in most markets, but rather divide up the markets and crush smaller local competitors.  Did I mention that the insurance industry is exempt from federal anti-trust laws? The American Medical Association’s 2007 report “Competition in health insurance: A comprehensive study of U.S. markets,” found that in the majority of areas studied, a single health insurer dominated the market.  So much for competition.

The field these behemoths compete on is in Washington, DC. They can buy and sell Senators and dominate regulatory agencies.  More on that later after we come back to the story in Indiana.

In the early 90’s the Hoosier Blue Cross leadership decided that the future looked bleak for non-profit health insurance.  They began a series of maneuvers to radically restructure the company.  They took off the gloves.  Goodbye to a charitable mission.  Goodbye to being tax-exempt.  Hello Wall Street.

Blue Cross became Anthem turning a non-profit into a mutual company.  This set the stage for demutualization and a public stock offering (IPO).  In 2001 Anthem announced its intention to convert from a mutual insurance company to a stock corporation and filed its demutualization proposal with the Indiana Department of Insurance.  By this time Anthem had already completed a frenzy of mergers and acquisitions of Blues in Colorado, Connecticut, Kentucky, Maine, New Hampshire, Nevada, and Ohio. None of policyholders in those states had any say in this matter. Just days after the Indiana Department of Insurance commissioner approved Anthem’s demutualization proposal, Anthem announced that its IPO had yielded $1.7 billion.

Now came the mother of all mergers.  Blue Cross of California had been following a similar path beginning with their demutualization in 1993 and subsequent acquisition of Blues in Missouri, Georgia, Virginia, and Wisconsin, as well as acquiring the health divisions of Massachusetts Mutual, and John Hancock, among others. They changed the corporate name to WellPoint. In 2004 Anthem and WellPoint merged, becoming the largest health insurer in the US with 34 million lives covered.

The $20.8 billion merger created a cornucopia of compensation for executives of both parent companies.   Not only did Anthem’s Indiana CEO Larry Glasscock receive a $42.5 million dollar bonus on top of his base salary of $3.7 million, other top Hoosier executives pocketed $4 to $16 million dollars each.  The CEO of WellPoint in California, Leonard Schaeffer, retired on a package valued at $337 million.  I am not making this up.

At the close of 2009, hope is gone that we will see universal health coverage come out of this Congress.  Single payer advocates like myself never really believed it might come this time around, but couldn’t help but get our hopes up.  It remains to be seen whether any bill that passes will end up being an incremental step in the right direction, but it won’t be a slippery slope.

Our Hoosier “Democratic” Senator Evan Bayh has distinguished himself as a hindrance to any reform bill that is not in the best interests of the hometown insurance company.  Although he and his wife Susan proclaim no conflict of interest, she sits on the WellPoint board.  Her compensation for serving on that board, as reported to the Securities and Exchange Commission, is $330,000 a year, more than twice Evan’s salary of $160,000 as a senator.

Progressives disagree about how to proceed from here.  I spoke with T R Reid a few weeks ago in Boston.  He is the author of the PBS Frontline Sick Around the World and a new book,  The Healing of America. He makes a strong case for getting to universal care while keeping the private insurance industry, although he makes it clear that no nation has achieved universal care using for-profit companies.

Can universal health care be accomplished within our system of for-profit insurance companies?  I’ve always favored the single payer approach, which seems more feasible to me than taming the insurance behemoths.  Reid thinks we’ve got to consider the taming approach, so some of us decided to put that idea to the test, in the form of a shareholder resolution.

We delivered the resolution on that dark and rainy day.  Now we await word about whether the SEC will require WellPoint to include it in the proxy for the annual meeting.  It is a long shot, to be sure.  But if Congress won’t take on the insurance industry, then someone has to.  Here is our resolution, couched in the language our legal advisors recommended and adhering to all SEC requirements:

SHAREHOLDER RESOLUTION

Whereas, the United States allows too many people to suffer and die due to lack of adequate health insurance and this is threatening the economic stability of the country; and

Whereas, no country has achieved universal healthcare through for-profit health insurance; and

Whereas, in written statements WellPoint supports “the best healthcare value for our customers” and promises  “to advocate for responsible healthcare reform”; and

Whereas, WellPoint has actively opposed President Obama’s healthcare reform efforts; and

Whereas, WellPoint was a nonprofit insurance company before it demutualized, raised capital through stock offerings, merged with, acquired, and demutualized other nonprofit Blue Cross/Blue Shield companies; therefore be it

Resolved, that the shareholders of WellPoint urge the board of directors to launch a feasibility study for returning to nonprofit status.  This study, conducted at reasonable cost, with results made available to the stockholders, omitting any proprietary information, should be completed within nine months of the 2010 shareholder meeting.

Supporting Statement:

Investors are concerned about the effects of runaway health costs on the economy, and the crisis of over 46 million uninsured.  Recent studies show 45,000 people a year die because they lack health insurance (American Journal of Public Health 9/17/09).   Tens of millions more are underinsured, able to afford coverage only through policies with huge deductibles and out of pocket expenses.  The impact of high deductible policies is seen in recent bankruptcy data showing 62% of personal bankruptcies caused by illness and medical bills, but 78% of those declaring bankruptcy for medical reasons had insurance when they became ill (American Journal of Medicine 8/09).  WellPoint has been a leader in marketing high deductible policies, specifically under the Tonik label.

From 1999 to 2008 American health insurance premiums increased 119% while workers earnings and overall inflation rose 30% (Bureau of Labor Statistics).  Businesses cannot continue to afford covering their employees. The Hewitt Associates study “The Road Ahead: 2009” found 1 in 5 employers are planning to drop health benefits in the next 3 to 5 years.  This system is unsustainable.

Studies show 31% of US healthcare spending is attributed to overhead.  In comparison, Medicare runs 3.1% overhead.  Most other developed nations spend less than 10% on overhead (New England Journal of Medicine 8/21/03).  Nations with universal systems spend about half what we spend on a per capita basis and have better health outcomes (Organization for Economic Cooperation and Development).

WellPoint reported its third quarter 2009 medical loss ratio at 81.1%.  Medical loss ratio is the percentage of premiums that actually pays for care, and thus corresponds to 18.9% of premiums for overhead and profit.  Although this is good for WellPoint’s profitability and share price, it supports the argument that for-profit health insurance is a major reason for the discrepancy in overhead expenses between the US and other countries.

WellPoint’s reputation has suffered as a consequence of the negative publicity surrounding its efforts to oppose healthcare reform.  This resolution could change that.

I’ll keep you posted on our progress,

Rob

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

Polls Hacker relies on in his 2007 paper

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Summary

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

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

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

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

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

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

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

Saving our children from THEIR deficit

Posted by on Friday, Dec 11, 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.

Taming the Deficit

Saving Our Children from Themselves

By David Rosnick and Dean Baker
Center for Economic and Policy Research (CEPR)
December 2009

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.

http://www.cepr.net/documents/publications/taming-the-deficit-2009-12.pdf

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.

http://www.wfpl.org/2009/12/10/healthcare-protest-held-outside-mcconnells-office/

Lesson for Congress: Medicare Advantage

Posted by on Thursday, Dec 10, 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.

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.

http://energycommerce.house.gov/index.php?option=com_content&view=article&id=1851:new-report-highlights-medicare-advantage-insurers-higher-administrative-spending&catid=122:media-advisories&Itemid=55

Full report:
http://energycommerce.house.gov/Press_111/20091209/MedicareAdvantageReport120909.pdf

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.

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