This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Comparing the Cost and Coverage Impacts of the House and Senate Leadership Health Reform Bills: Long Term Costs for Governments, Employers, Families and Providers
Prepared for: The Peter G. Peterson Foundation
By John Sheils and Randy Haught
The Lewin Group
December 7, 2009
Impact on National Health Spending
Both bills would result in an increase in administrative costs. These include the cost of administering private insurance to newly covered people, the cost of administering coverage under Medicaid and the cost of processing eligibility for premium subsidies under the bill.
Both bills would result in a substantial growth in national health expenditures. Total health spending over the 2010 through 2029 period would increase by $781 billion under the Senate bill and $955 billion under the House bill.
What is health care reform going to cost us? To help answer this question, numerous reports have been generated by the Congressional Budget Office (CBO), the Office of Management and Budget (OMB), the Office of the Actuary of the Centers for Medicare and Medicaid Services (CMS), the Council of Economic Advisers (CEA), private foundations, and numerous consulting firms representing the private insurance industry.
Although politicians are using sections of these reports selectively to advance their own agendas, if you read all of the reports you cannot escape the conclusion that the measures designed to slow the growth in health care costs do not begin to offset the anticipated increases in spending. Further, they show that an unacceptable number of individuals will remain amongst the ranks of the uninsured.
This new, highly credible report (credible in spite of ownership by UnitedHealth) by John Sheils and Randy Haught draws the same conclusions. National health expenditures will increase over the amounts projected were there no reform, and about 20 million people will still be uninsured.
One comparatively small number in this report is that administrative costs will increase by about $87 billion in the next decade under either the Senate or the House bill. But this number has much greater significance than the amount would suggest. Not only is this an additional cost, it also adds on to the $4,000 billion in administrative waste that we could recover in the next decade if we merely changed to a single payer system of financing health care. That would free up enough funds to cover our nation’s unmet health care needs.
The following letter to the editor by Dr. Howard Green of Florida was sent to the New England Journal of Medicine in early November. It had not yet been published as of the Dec. 10 issue.
The New England Journal of Medicine (NEJM) has had a decades-old policy of financial disclosure by authors of editorials in order to “prevent financial interests from infringing on the editorial content of the Journal.”
This policy was grossly violated when the editors of the NEJM recently chose to publish an opinion piece by Senator Max Baucus titled “Doctors, Patients, and the Need for Health Care Reform” (Vol. 361:1817-1819, Nov. 5, 2009, No. 19) that included a statement by the author that he had no financial interests to disclose.
In the past year alone, Sen. Baucus has received payments from drug and health insurance companies many times in excess of the $10,000 limit which the Journal recognizes as significant to alter an author’s credibility. By failing to disclose those contributions to Journal readers, Sen. Baucus and the editors of the NEJM have violated their own code of ethics and disclosure meant to support the veracity of opinions and data presented in their journal.
Disclosure of the senator’s directly or indirectly received payments from health insurance and pharmaceutical companies would help readers understand why Sen. Baucus continues to support a government-subsidized, high-overhead, low-outcome private insurance industry operating parallel to and within Medicare insurance.
Disclosure of the senator’s receipt of such “contributions” from the health care sector might demonstrate why he supports a private health insurance industry that siphons away, via administrative overhead, hundreds of billions of dollars annually from physician subscribers to the NEJM, patients, clinics, therapists, and pharmacies.
In addition to failing to disclose in the NEJM the monies he has received from pharmaceutical and health insurance companies, Sen. Baucus failed to inform readers of his personal and his Senate Finance Committee’s continued support for (or acquiescence to) the following policies:
* A federal exemption for private health insurance companies from antitrust regulations.
* A prohibition on Medicare insurance establishing a drug formulary through competitive bidding.
* No federal grants to develop a single EMR and billing system for physicians, hospitals and therapists which would reveal clinical, preventative and surgical outcomes. Outcome revelations would crush the health insurance companies, and allow for free-market competition among doctors and hospitals based on quality and efficiency.
* Protection of private health insurance companies from medical malpractice lawsuits via federal ERISA laws.
* Part D taxpayer subsidies to health insurance and drug corporations.
* Medicare Advantage taxpayer subsidies to health insurance companies.
* Reckless and negligent medical rationing by private health insurance companies via their non-physician employees.
* A government ban on collective bargaining by physicians.
* An inability of Medicare to enlarge its limited risk pool beyond that of the oldest, sickest and most physically disabled citizens of our nation.
* Personal bankruptcies due to a medical illness.
* No real change in malpractice reform. Real malpractice reform would allow internists and family practitioners to fulfill their role as primary care physicians efficiently and productively, tackling dynamic illnesses without prematurely referring their sicker patients to expensive specialists without medical benefit.
By allowing Sen. Baucus to express his opinion without a comprehensive disclosure of the large sums he has received from health insurance and pharmaceutical companies or of his continued support of current health care policies, the editors of the NEJM have surrendered their objective status as an advocate of integrity in research and patient care.
Howard A. Green, M.D., FACP, FAAD, FACMS
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
By now I’m accustomed to being the only person in any given room with my particular set of cockamamie politics. But even within the more familiar confines of the libertarian movement, I am an awkward outlier on the topic of the day (and the topic of this issue of reason): health care.
To put it plainly, when free marketers warn that Democratic health care initiatives will make us more “like France,” a big part of me says, “I wish.” It’s not that I think it’s either feasible or advisable for the United States to adopt a single-payer, government-dominated system. But it’s instructive to confront the comparative advantages of one socialist system abroad to sharpen the arguments for more capitalism at home.
For a dozen years now I’ve led a dual life, spending more than 90 percent of my time and money in the U.S. while receiving 90 percent of my health care in my wife’s native France. On a personal level the comparison is no contest: I’ll take the French experience any day. ObamaCare opponents often warn that a new system will lead to long waiting times, mountains of paperwork, and less choice among doctors. Yet on all three of those counts the French system is significantly better, not worse, than what the U.S. has now.
What’s more, none of these anecdotes scratches the surface of France’s chief advantage, and the main reason socialized medicine remains a perennial temptation in this country: In France, you are covered, period. It doesn’t depend on your job, it doesn’t depend on a health maintenance organization, and it doesn’t depend on whether you filled out the paperwork right. Those who (like me) oppose ObamaCare, need to understand (also like me, unfortunately) what it’s like to be serially rejected by insurance companies even though you’re perfectly healthy. It’s an enraging, anxiety-inducing, indelible experience, one that both softens the intellectual ground for increased government intervention and produces active resentment toward anyone who argues that the U.S. has “the best health care in the world.”
Don’t even get me started on the Kafkaesque ordeal of switching jobs without taking any time off, yet going uncovered by anything except COBRA for nearly two months even though both employers used the same health insurance provider. That incident alone cost me thousands of dollars I wouldn’t have paid if I had controlled my own insurance policy.
I’ve now reached the age where I will better appreciate the premium skill level of American doctors and their high-quality equipment and techniques. And in a very real way my family has voted with its feet when it comes to choosing between the two countries. One of France’s worst problems is the rigidity and expense that comes with an extensive welfare state.
But as you look at the health care solutions discussed in this issue, ask yourself an honest question: Are we better off today, in terms of health policy, than we would have been had we acknowledged more loudly 15 years ago that the status quo is quite awful for a large number of Americans? Would we have been better off focusing less on waiting times in Britain, and more on waiting times in the USA? It’s a question I plan to ask my doctor this Christmas. In French.
(Matt Welch is Reason’s editor in chief.)
Reason magazine is a publication of Reason Foundation, a libertarian organization advancing “free minds and free markets.” In this refreshing moment of candor, Reason’s editor in chief, Matt Welch, does not allow libertarian ideology to cloud the truth about the contrasts between our health care system in the United States and France’s system of social insurance.
He has not abandoned his libertarian ideology in that he seems to reject a single payer system for the United States, while suggesting that France’s “socialist system” can “sharpen the arguments for more capitalism at home.” Yet when he describes the superiority of the French system he is describing attributes of social insurance and not free market capitalism. Including these favorable attributes in the U.S. capitalist system would be impossible without significantly expanding the government role in health care.
He states the he opposes “ObamaCare,” yet for what reason? Although he may be wishing that a capitalistic free market in private health plans would accomplish what France’s social insurance program does, he provides evidence of the opposite. His opposition to the current proposal before Congress seems to be for the same reason that we oppose it. It falls far short of the goals of social insurance. It will not be universal, comprehensive, affordable, equitably funded, adequately risk-adjusted, efficiently administered, nor would it apply the principles of social solidarity that make all other systems more efficient and effective than ours.
Under the proposal, most of our health care system remains the same, with little fundamental change in either employer-sponsored coverage or in our public programs such as Medicare and Medicaid. One advantage for those who “can keep the insurance they have” was to have been removal of the cap on yearly medical costs, but even this promise seems to have been abandoned. Although reform will nominally provide coverage for a portion of the uninsured (falling far short of the goal of universality), it will compound the affordability problem for middle-income Americans though inadequate controls on cost escalation, higher taxes, and higher premiums and out-of-pocket expenses (the opposite of what we were promised).
The nation should listen when a prominent libertarian extolls the virtues of social insurance. Once we accept the principle of social insurance, then we can have a more rational debate over whether we want that to be a single-payer Medicare-type program or a European-style social insurance program using using private plans that are so tightly regulated that they almost function as a single payer system. Though PNHP will continue to advocate for the golden standard of a single payer system, that is the debate that we should be having.
Regardless, we need to dump the current proposal and immediately move on with a reform process that will establish a bona fide social insurance program within the United States. Otherwise Matt Welch will have to keep outsourcing his personal medical care to France.
Two-thirds of Americans support Medicare-for-all (#5 of 6)
Celinda Lake’s “research” for the Herndon Alliance
By Kip Sullivan, JD
One key player was Roger Hickey of the Campaign for America’s Future [CAF]. Hickey took … Jacob Hacker’s idea for “a new public insurance pool modeled after Medicare” and went around to the community of single-payer advocates, making the case that this limited “public option” was the best they could hope for. … And then Hickey went to all the presidential candidates, acknowledging that politically, they couldn’t support single-payer, but that the “public option” would attract a real progressive constituency…
The rest is history. Following Edwards’ lead, Barack Obama and Hillary Clinton picked up on the public option compromise.
So what we have is Jacob Hacker’s policy idea, but largely Hickey and Health Care for America Now’s political strategy. It was a real high-wire act – to convince the single-payer advocates, who were the only engaged health care constituency on the left, that they could live with the public option as a kind of stealth single-payer, thus transferring their energy and enthusiasm to this alternative.
That is how Mark Schmidt summed up the strategy of the “public option” movement in a short piece for the American Prospect last August. Schmidt’s analysis, rarely seen anywhere else in the media, was correct. I would have added two details to Schmidt’s article.
First, Hickey and other “option” advocates attempted to justify their abandonment of single-payer by claiming most Americans opposed it. This “people don’t like it” version of the “political feasibility” argument against single-payer was new. Prior to the emergence of the “public option” movement, those who refused to support single-payer on “political feasibility” grounds claimed the insurance industry was too powerful to beat. They did not assert that Americans were opposed to single-payer, no doubt because they knew such a statement was demonstrably false.
The other weakness in Schmidt’s analysis was his failure to mention the Herndon Alliance, “the most influential group in the health care arena the public has never heard of,” as Carrie Budoff Brown put it in an article for Politico. It was the Herndon Alliance (of which CAF is a member) which manufactured the “evidence” that Hickey and other “option” advocates cited when they were making the rounds to Democratic candidates and progressive groups to urge them not to support single-payer and to support the “option” instead. It was the evidence they needed to state, with a straight face, “Americans are scared to death of single-payer,” to quote CAF’s Bernie Horn once more. (For information on the origins of the Herndon Alliance and Lake’s “research” for the Alliance, see my paper here.)
The Herndon Alliance hired pollster Celinda Lake to produce the evidence they were looking for. Lake delivered the goods. Over the course of 2006 and 2007, she conducted focus group sessions and carried out at least two polls. By the fall of 2007, Lake turned over to the Herndon Alliance the results they had asked for. Lake “found” that “people” don’t like single-payer. Instead they like something Lake called “guaranteed affordable choice,” a label that would be changed two years later to “the public option.”
Roger Hickey, for one, wasted no time putting Lake’s “research” to use. In November 2007, at an event sponsored by New Jersey Citizen Action, a chapter of USAction (a member of the Herndon Alliance and the soon-to-be-formed Health Care for America Now), he made this statement:
[T]he hard reality, from the point of view of all of us who understand the efficiency and simplicity of a single-payer system, is that our pollsters unanimously tell us that large numbers of Americans are not willing to give up the good private insurance they now have in order to be put into one big health plan run by the government. Pollster Celinda Lake looked at public backing for a single-payer plan – and then compared it with an approach that offers a choice between highly regulated private insurance and a public plan like Medicare. This alternative, called “guaranteed choice,” wins 64 percent support to 22 percent for single-payer.
I won’t bother asking why Hickey and the Herndon Alliance didn’t rely on the citizen jury and polling data I reviewed previously (in Part 2 and Part 3) that show two-thirds of Americans support a Medicare-for-all system. But it is worth raising this question: Why didn’t Hickey and the Herndon Alliance cite the polls that Jacob Hacker relied on? Why commission Lake to do more “research” when Hacker was already convinced he had the evidence necessary to undermine the single-payer movement? By November 2007, when Hickey spoke to New Jersey Citizen Action, Hacker had published several papers examining polling data (including the 2006 and 2007 papers I reviewed in Part 4.)
I suspect the reason is that the Herndon Alliance didn’t find Hacker’s papers as compelling as Hacker did. They felt they needed research that produced more than the equivalent of a Rorschach blot. They needed research that focused specifically on single-payer and the public-private-plan choice proposal.
Lake’s “research”: “Mysterious forces” and “discount consumerism” are “values”
We had people in our focus groups saying, “Well, this is Canadian-style health care,” and we found that the answer was, “No, no. This is American health care.” And people would go, particularly those proper patriots who just love America, “Oh, well great. Then it’s got to be better. This is much superior.” Now the irony is … that American-style health care does not include Medicare for all or a system-wide social security, both of which are frankly frighteningly flawed programs in the voters’ minds. (page 44)
These words were spoken by pollster Celinda Lake at a September 29, 2006 conference sponsored by the Herndon Alliance, just two weeks before Slate published the article by Jacob Hacker that I examined in Part 4. But whereas Hacker was misinterpreting polls taken by polling firms over which he had no control, Lake was accurately reporting on the “first round” of her own “research” over which she had complete control. Her “research” was based on discussions with eight focus groups, each with eight to ten people, which her firm convened in Columbus, Ohio and Atlanta, Georgia in July and August of 2006 (see footnote 2 in Celinda Lake et al., “Health care in the 2008 election: Engaging the voters,” Health Affairs 2008; 27:693-698).
But Lake shared Hacker’s agenda: to demonstrate that Americans like the existing health insurance system and fear a Medicare-for-all system. Hence her celebration of “patriots” and their disdain for “Canadian-style health care.” Hence her trashing of Medicare as a “frighteningly flawed program.” Hence her recommendation that universal coverage advocates assiduously avoid the phrase “Medicare for all” in favor of “choice of public and private plan” (see page 81 of Lake’s presentation.)
At another Herndon Alliance conference held in November 2007, convened to hear Lake’s “findings” from ten more focus groups that were held in Denver, Colorado, Concord and San Diego, California, Columbus, Ohio, and Orlando, Florida during June and July of 2007, Lake continued her assault on the idea that Americans would support a single-payer system. Again she claimed the people in her Atlanta and Columbus focus groups couldn’t stand the thought of Medicare-for-all or what she insisted on calling “Canadian-style health care”:
[W]e found that people want an American solution. My favorite epiphany is in the first round of work was everybody [says], “It’s going to be Canadian style health care.” Americans don’t want Canadian style-health care. They want American health care. (page 17)
To make sure their audience got this point, the Herndon Alliance entitled this conference, “American Values, American Solutions.”
So what did Lake discover from her 2007 focus groups that “people” did like? Amazingly, they liked exactly what Hacker had recommended a year earlier in his Slate article and six years earlier in a paper written for the Robert Wood Johnson Foundation. “People” liked having a choice between private health insurance and a public program.
As Lake put it:
People don’t want to go to a government health care system. But they do like the idea of the government as the enforcer, the watchdog, the setter of standards, as you will remember in the first research. … [I]n the second round research we found … that they were fine with government offering a public plan. In fact they thought there was a lot of merit to having a choice between a private plan and a public plan. (page 15)
Lake had presented to her 2007 focus groups what she called a “guaranteed affordable choice” proposal – a proposal that would give all Americans a choice between private insurance and a publicly run insurance program. Did she also present to them an accurate description of single-payer? Almost certainly not, but we’ll never know for sure. Unlike the groups that convened the citizen juries I described in Part 2, Lake refuses to release the methodology she used in questioning her focus groups.
Lake has, however, released an extensive description of her methods for selecting her focus groups. This methodology is just plain bizarre. Lake says she or the Herndon Alliance (it is not clear which) hired a Fortune 500 consulting firm called American Environics to compile a list of 117 American “core values that shape … views on health care.” The list of “values” included one pop-psychology phrase after another that might make sense to the marketing department of L’Oreal (one of the firms American Environics boasts it consults with) but are laughably irrelevant to the US health care reform debate.
Among the 117 “values” were “brand apathy,” “discount consumerism,” “upscale consumerism,” “more power for big business,” “meaningful moments,” “mysterious forces,” “traditional gender identity,” and “sexual permissiveness.” “Discount consumerism” was defined, for example, as “preferring to buy discount or private label brands, often from wholesalers.” “Meaningful moments” was described as, “The sense of impermanence that accompanies momentary connections with others does not diminish the value of the moment.” (For a complete listing of these 117 “values,” starting with “acceptance of violence” and ending with “xenophobia” – defined as “too much immigration threatens the purity of the country” – see the appendix to the American Environics’ report here.)
On the basis of these “values,” Lake somehow divided Americans into eight groups and gave them names like “Proper Patriots” and “Marginalized Middle-Agers.” Here is how Lake explained this process at the November 2, 2007 Herndon Alliance conference:
One of the things that we also did in the Herndon process was to identify key constituencies of opportunity at the values level. (page 20)
She then selected her focus groups to reflect these groupings. Notice how different this method of selecting focus group participants is from the method used by the organizers of the citizen juries I discussed in Part 2. The organizers of those events sought to select jurors who represented a cross-section of America. It seems highly unlikely that a “methodology” that involved quizzing prospective focus group participants about “meaningful moments” and “brand apathy” would result in focus groups that represented a random sample of the American adult population.
Celinda Lake’s poll
The statements Lake made at Herndon Alliance meetings about how “people” feel about Medicare and “guaranteed affordable choice” were based on her focus group “research.” The statistic Hickey quoted – “voters” choose “guaranteed affordable choice” over single-payer by a margin of 64 percent to 22 percent – was produced by a poll Lake’s firm conducted in September 2007. (See page 23 of Lake’s presentation.)
The poll asked this question:
Which of the following two approaches to providing health care coverage do you prefer?
• An approach that would guarantee affordable health insurance coverage for every American with a choice of private or public plans that cover all necessary medical services, paid for by employers and individuals on a sliding scale; or
• a single government-financed health insurance plan for all Americans financed by tax dollars that would pay private health care providers for a comprehensive set of medical services.
(See page 18 of Lake’s presentation.)
There are four choices involving words or omission of facts that introduced bias into this question. But before we examine those biases, I want to call the reader’s attention to how badly Hickey misrepresented Lake’s poll. Hickey said “our pollsters unanimously tell us that large numbers of Americans are not willing to give up the good private insurance they now have in order to be put into one big health plan run by the government.” That’s not what Lake’s poll said, even taking it at face value. Her poll asked respondents, “Which of two approaches … do you prefer”? A question that asks about preferences cannot be interpreted as evidence of what Americans “are not willing” to do. If I ask you if you prefer tea or coffee, and you say coffee, I can’t claim you “are not willing” to drink tea. I can only claim you prefer coffee over tea.
Here are four biases Lake introduced into her poll:
(1) The definition of single-payer includes the words “government” and “tax” while the definition of “guaranteed affordable choice” does not.
(2) The “tax” in the definition of single-payer is not described as “progressive” or “sliding scale,” but financing is described as “sliding scale” in the “guaranteed affordable choice” definition.
(3) The “guaranteed affordable choice” option is presented as if it were possible to “guarantee … health insurance for every American” without taxes, that is, without compulsory payments of some sort. The “guaranteed affordable choice” option is described as “paid for by employers and individuals.” That has a much more voluntary ring to it than “tax.” But in fact no system of universal coverage can be achieved without compulsory payments of some sort by the populace. If Lake and her colleagues in the “option” movement are actually claiming the “guaranteed affordable choice” proposal will establish universal health insurance, then they cannot ethically describe single-payer’s funding source as “taxes” and not describe the payments by “employers and individuals” under the “guaranteed affordable choice” proposal as taxes.
(4) Perhaps most importantly, Lake’s poll failed to explain the real consequences of the “guaranteed affordable choice” proposal. These include the fact that Americans will not regain their freedom to choose their own doctor under “guaranteed affordable choice” or any other proposal that leaves the current health insurance industry in place. Another unmentioned fact is that “guaranteed affordable choice” cannot cut costs, which means taxes and/or compulsory payments will have to be higher and/or that coverage will be worse under the “guaranteed affordable choice” proposal.
Even if Lake’s poll had asked about opposition to single-payer and “guaranteed affordable choice” rather than preferences between them, the poll was too biased to produce reliable results. Like the amorphous polls Hacker relied on, and like Lake’s focus group “research,” Lake’s poll is no match for the rigorous research that shows that two-thirds of Americans support single-payer.
Invoking the ends to justify the means
There was a time when Celinda Lake was more interested in the truth than in pleasing her patrons. In the early 1990s, Lake conducted polls and focus groups which led her to conclude that Medicare is a very popular program and that large majorities of Americans support a Medicare-for-all or single-payer system. In 1992, before she went to work for the Clinton administration and long before she went to work for the Herndon Alliance, Lake published an article in the Yale Law and Policy Review in which she made these statements:
Americans believe that the market system has failed completely in the medical arena. Their disillusionment with the private health insurance industry leads them to believe that even a governmental bureaucracy would prove more efficient and provide less costly health care. In one western state, two-thirds of voters agree that health costs have surged so high that only a government health-care system can bring them under control. Almost two-thirds (62 percent) reject the idea that private industry will keep medical costs cheaper than would a government-run system with cost controls…. Sixty-nine percent support a universal government-paid system similar to the Canadian system…. Voters strongly support a national health-care system that mirrors or expands Medicare and see no reason why such a system cannot be established. National health-care reformers would do well to talk in terms of expanding Medicare. Just mentioning the words “Medicare-like system” increases voters’ support for any described system by about 10 percent. Framing the issue this way increases support across all age groups…. (Celinda Lake, “Health care: The issue of the nineties,” Yale Law and Policy Review 1992;10(2):211-224).
In 1993, Jeff Cohen and Norman Solomon quoted Lake saying that the more people know about single-payer the more they like it. Cohen and Solomon wrote:
After conducting extensive focus groups on health care, pollster Celinda Lake discovered that the more people are told about the Canadian system, “the higher the support goes.”
In these excerpts, Lake sounds just like me and every other single-payer advocate in America – and very unlike the Celinda Lake of today. Her statements that two-thirds of Americans support single-payer, that likening a proposed reform to Medicare “increases voters’ support … by about 10 percent,” and that support for single-payer rises as people learn more about it could have been made by any knowledgeable single-payer advocate at any time over the last two decades.
So what explains the difference in Celinda Lake’s findings and recommendations in 1992 and 1993 and her “findings” and recommendations post-2005? Did American support for single-payer really head south during those years? Did support really fall from the 69-percent level Lake reported in 1992 to the 22 percent level that Lake “found” in 2007 and which Roger Hickey so enthusiastically reported to New Jersey Citizen Action that year? The citizen jury experiments and the survey research I reported in Parts 2 and 3 of this series, as well as a large body of other relevant evidence I have not reviewed (such as the undiminished popularity of the Medicare program despite constant attacks on Medicare by the right) demonstrates that public support for single-payer did not fall over those years.
What changed was Celinda Lake’s attitude about single-payer. Apparently, Lake came to believe what Jacob Hacker believes: that politics must be elevated above policy; that means may be justified by the ends; that corrupt “research” may be pawned off as rigorous research if the cause is good enough; and that the single-payer campaign may be sabotaged for the higher good as defined by the leaders of the “public option” movement. Lake apparently came to believe, to quote an infamous memo, that “the facts” were going to have to be “fixed around the policy” and that it was her job to create the “facts.”
Stay tuned for the conclusion, Part 6: “Should polls matter?”
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:
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.
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,
Two-thirds of Americans support Medicare-for-all (#4 of 6)
Jacob Hacker’s ambiguous polls
By Kip Sullivan, JD
In Part 2 and Part 3 of this series I reviewed rigorous evidence from multiple sources supporting the statement that somewhere between 60 and 80 percent of Americans support a Medicare-for-all system. A reasonably conservative averaging of the more rigorously conducted research I reviewed – the citizen jury results and the results of polls that asked accurate and relatively informative questions – indicates two-thirds of Americans support a single-payer or Medicare-for-all system.
In this part and in Part 5, I will examine the basis for the claim by representatives of the “public option” movement that only a minority of Americans support single-payer and a majority are opposed. The basis for that claim consists primarily of several papers written by Jacob Hacker and “research” done for the Herndon Alliance by pollster Celinda Lake. Until about two years ago, Hacker wrote about health policy primarily for the academic community; since then he has published frequently in the lay media. Since its formation in 2005, the Herndon Alliance has sought to create “research” that could be used to persuade the public, especially legislators and political activists, that single-payer should be taken off the table and the “public option” should be put on the table. I review Hacker’s work in this paper and Celinda Lake’s in Part 5.
Expediency-driven health policy
It may sound sacrilegious to say this …, but the greatest lesson of the failure of the Clinton health plan is that reformers pay too much attention to policy and too little to politics. If real estate is about location, location, location, health reform is about politics, politics, politics.
Thus spake Jacob Hacker in a paper published in Health Affairs in 2008 entitled, “Putting politics first.” Hacker argues that anyone who wants to achieve universal health insurance must somehow separate “politics” from “policy” and give highest priority to politics. If Hacker had merely said that anyone who seeks to achieve universal health insurance should devote resources to building public pressure for it, his statement would be incontrovertible. It would be a truism. But Hacker’s “politics, politics, politics” statement went beyond the truism that “reformers” must build a movement for universal health insurance.
Hacker’s demand that we distinguish between politics and policy and give high value to one and low value to the other is nonsensical. It’s equivalent to saying that process is separate from and matters more than outcome, or that means are separate from and matter more than ends. To make such a distinction amounts to an endorsement of opportunism and expediency. We will see in the remainder of this article that in fact that’s where Hacker’s “put politics first” mantra leads him. It leads him to attribute to the public anti-single-payer, pro-insurance-industry attitudes based on polling data that are so abstract they offer no guidance at all. As the events of 2009 have demonstrated, the exaltation of expediency – dressed up as political science – produces neither good policy nor good political strategy.
Unlike the Herndon Alliance, which commissioned its own polling and focus group “research,” Hacker relied on existing polling data to support his conclusion that single-payer is not feasible while the “public option” is. Hacker cites different types of polls depending on whether he is addressing the general public or health policy experts. His 2006 article for Slate cited one set of polls. A 2007 paper that he co-authored with Mark Schlesinger (“Secret weapon: The ‘new’ Medicare as a route to health security,” Journal of Health Politics, Policy and Law 2007;32:247-291) cited another set of polls. Inexplicably, neither paper discussed the Jefferson Center jury results I discussed in Part 2 nor the polls showing large majorities for single-payer that I discussed in Part 3 of this series.
In the course of examining these two papers, I will review in detail seven polls that Hacker cites. This may get tedious, but it’s important that you see for yourself how nebulous Hacker’s “evidence” is. Once you behold Hacker’s “evidence” directly, you realize that Hacker’s belief that Americans oppose single-payer is based entirely on polling results that resemble a Rorschach ink blot. You can see in them what you want to see. Where you and I might discern a public ready to support single-payer, Hacker discovers hulking impediments to single-payer.
Polls Hacker cited in his Slate article
Hacker’s article for Slate bore the condescending title, “Better medicine: Fixing the left’s health care prescription.” The problem in need of “fixing,” according to Hacker, was “the left’s” support for single-payer. Hacker urged “the left” to support instead his proposal to “give employers the option of providing … coverage to their workers through a new public program modeled after Medicare” or through the insurance industry, a proposal that would, by 2009, be called “the public option” for short.
Hacker grudgingly acknowledged single-payer’s advantages, but then claimed single-payer advocates were “biting off too much.”
Americans like Medicare, and yes, Medicare is easy to explain. But that doesn’t mean most people are ready to say everyone should be covered by Medicare. Many of us remain stubbornly attached to employment-based health insurance, and proposing to abolish it entirely is likely to stir up fear as well as gratitude.
He hyperlinked the words “stubbornly attached” to an article in Mother Jones written by the Century Foundation. (In the fullness of time, the Century Foundation became a passionate advocate for the “public option.”) The Century Foundation article reviewed several polls on American attitudes about “universal coverage.” Amazingly, one of them was the 2003 Washington Post/ABC News poll showing 62 percent support for a Medicare-for-all system that I discussed in Part 3. Does Hacker read the documents he cites as evidence for his own claims?
Before we examine the Century Foundation’s article, I want call your attention to three features of Hacker’s argument.
First, he practices “put politics first.” He says that even though single-payer is a good proposal, it should be rejected entirely. It would be one thing to counsel single-payer advocates against trying to get a full-blown single-payer system enacted in a single session of Congress and to plan instead for a multi-year campaign (which is fact what the single-payer movement has been doing for two decades). But Hacker is not doing that. He is urging progressives to reject single-payer completely.
Note second that Hacker urges us to accept whatever polls say as the final arbiter of what is politically feasible. Hacker has no interest in a very obvious question: If everyone who supports universal coverage threw their weight behind the campaign for single-payer, how much higher could public support for single-payer be raised?
Third, Hacker can’t bring himself to say how many Americans are “stubbornly attached” to employer-based health insurance. He can only bring himself to say “many.” If Hacker is going to rest his entire argument that the “left” should abandon single-payer on the premise that “we” are “attached” to the current system, why is he so vague about what proportion of the populace he is talking about?
I urge readers to examine the Century Foundation article for yourself. Focus on the “What we know” section (it’s only a page long), which is where the poll results are discussed. It will become obvious quickly that this article provides no basis at all for Hacker’s claim that Americans are “stubbornly attached” to the current system. At most, only three paragraphs have any relevance to that claim, and these paragraphs produce results that are at best ambiguous and at worst (from Hacker’s point of view) supportive of single-payer.
Consider the two excerpts from the Century Foundation summary I quote below. The first asserts the public wants to replace “the current employer-based system” (yes, the very same “employment-based” system to which Hacker says “many of us remain stubbornly attached”). The second excerpt, which appears barely a half-page later, asserts just the opposite.
The public wants the government to play a leading role in providing health care for all. For example, in an October, 2003 Washington Post/ABC poll, by almost a two-to-one margin (62 percent to 33 percent), Americans said that they preferred a universal system that would provide coverage to everyone under a government program, as opposed to the current employer-based system.
The public generally wants to build on, rather than eliminate, the current employer-based private health insurance system. In a January, 2000 Kaiser poll, they preferred building on the current system to switching to a system of individual responsibility (54 percent to 39 percent) and in a November 2003 Kaiser poll, they preferred keeping the current system to replacing it with a government-run system (57 percent to 38 percent). (emphasis added)
How does one make any sense of these conflicting statements? How does Hacker find in these statements proof that Americans (a) like the current employer-based system, and (b) like it so much they would oppose a single-payer system? In these excerpts, the author of this summary, Ruy Teixeira, gives us not only two contradictory statements to sort out (the public does and does not want to replace the “current employer-based system”), but we’re supposed to understand what “a system of individual responsibility” and “a government-run system” means.
If we track down the polls these excerpts refer to, we discover that we have already encountered these polls, or polls like them, in Part 3 of this series.
I discussed in Part 3 of this series the 2003 Washington Post/ABC poll that Teixeira cites in the first excerpt. That poll found 62 percent support for a single-payer system, described in that poll as “a universal health insurance program, in which everyone is covered under a program like Medicare that’s run by the government and financed by taxpayers.” So how does Teixeira account for the difference between the 62 percent support for single-payer he reports in the first excerpt and the 38 percent level of support one or both of two Kaiser polls (Teixeira isn’t clear which) reported for a “government-run system” in the second excerpt? He doesn’t say.
The Kaiser poll search engine (using the phrases “individual responsibility” and “government run”) and a Google search turned up only one of the two Kaiser polls Teixeira refers to in excerpt 2 above – the January 2000 poll. That poll, which Teixiera cited as evidence that Americans prefer “the current system” to a “system of individual responsibility,” reads as follows:
Which of the following, option one or option two, do you think would be the better way to guarantee health insurance coverage for Americans? Option One is, building on the current system in which employers contribute to their employees’ health insurance, which they get through their job, and the Government covers the cost of insurance for the poor and unemployed, or Option Two which is, switching to a system in which all individuals would buy their own health insurance but would receive a tax credit or subsidy to help them with the cost of the plan.
Fifty-four percent chose “the current system” versus 39 percent who chose what Teixeira called “a system of individual responsibility.”
In my last installment I discussed polls quite similar to the other (2003) Kaiser poll Teixeira cited (the one my search failed to turn up), a poll which, according to Teixeira, asked respondents to choose between “the current system” and “a government-run system.” The ominous phrase “government-run system” sounds very much like the frightening phrase “government-run health care system” conjured by the Gallup poll (discussed in Part 3). The 38-percent level of support Teixeira reports is within the range of Gallup poll results over the last decade – 32 to 41 percent – that I reported. This strengthens my hypothesis that the question Teixeira claims Kaiser asked in 2003 was very similar to the Gallup question. (It would help if people who urge readers to rely on polls for any reason would link readers to those polls or give more precise source information.)
The only other shred of information in the Century Foundation article that might give a “yes but” comfort was this excerpt, which again contained contradictory statements:
In a December 2003 Harvard School of Public Health/Robert Wood Johnson/ICR poll, 80 percent supported expanding Medicaid/SCHIP; 76 percent supported employers being required to offer a health plan; and 71 percent supported a tax credit plan. Trailing these options, but still garnering majority support, were a universal Medicare plan (55 percent) and an individual coverage mandate plan (54 percent). …. (Note: one of the only options that didn’t garner majority support … was a single or national health plan financed by tax payers that would provide insurance for all Americans [37 percent to 47 percent].)
Once again, Teixeira juxtaposes a poll showing majority support for single-payer (55 percent) with another poll showing 37 percent support, and offers no explanation for the difference. As you can see, the two single-payer questions Teixeira refers to appear to have been part of a line-up of another half-dozen questions or so, including questions about proposals that wouldn’t come close to achieving universal coverage and none of which would cut costs.
To sum up, the Century Foundation article Hacker linked his readers to for evidence of our “stubborn attachment” to the current system demonstrated nothing of the sort.
Polls Hacker relies on in his 2007 paper
In the paper he published in the Journal of Health Politics, Policy and Law in 2007 with Mark Schlesinger, Hacker argued for the “public option” and against single-payer. As he did in his Slate paper, Hacker argued that the “expectations” and “values” of the American people, not the insurance industry, constitute an intractable obstacle to single-payer. At the outset of this paper, in a section entitled, “Prevailing American values as barriers to universal health insurance,” Hacker sought to make two arguments: Americans value choice of health insurance company, and they are scared of their government. The data he relied on to make this case were even more abstract and ambiguous than the data he relied on in his Slate article. I’ll review the evidence he cites for his claim that Americans value choice among insurance companies first, and then examine the data he cites for his claim that Americans are afraid of a single-payer system.
Hacker’s argument that Americans value choice of health insurer (as opposed to provider) consisted almost entirely of these statements:
During the debate over health reform in the early 1990s, 81 percent of the public reported that it was important or essential for a proposal to give “people a choice of different types of health insurance plans” (Louis Harris and Associates in 1994). When asked whether “seniors should have the option of picking a private health plan approved by the Medicare program to provide their health benefits,” 82 percent of the public endorsed these choices (Zogby International 2003). Americans embrace choice of insurance not because they favor markets in health care per se but because they have so little trust in government, employers, or private insurance and want protection against problematic experiences (Blendon et al. 1998; Jacobs and Shapiro 1999).
Neither of the two polls and neither of the two papers Hacker cites support his conclusions. The papers deal exclusively with the backlash against managed care that occurred in the late 1990s. Those papers say nothing that could be construed as evidence that Americans “embrace choice of insurance” and have “little trust in government.” To give you some idea of how badly Hacker misinterpreted these papers, I have presented the abstract of the paper by Blendon et al. in the appendix to this paper (the Jacobs and Shapiro paper did not contain an abstract).
Now let’s look at the two polls Hacker cited to support his claim that Americans value choice of insurance company. The 1994 Harris poll posed this question:
As the Congress debates health care reform, they must consider several different goals. Please say for each of the following whether you think it is absolutely essential, very important, or not important …. Giving people a choice of different types of health insurance plans?
Thirty-six percent said “choice of… plans” was “absolutely essential” and 45 percent said it was “very important.” But does this poll demonstrate that Americans value choice of insurance company?
This poll was conducted during May 23 to 26, 1994, while the debate over the Clinton bill – a bill which would have pushed middle- and lower-income people into HMOs and other tightly managed health insurance companies – was still in full swing. The poll question deliberately asked respondents to think about the current debate in Congress and the “goals” that “Congress must consider.” The context in which this poll question was asked, and the opening statement to the question, must have induced all or most respondents to think they were being asked whether they would approve of Congress reducing their choice of insurance companies. It is not surprising they said no to this question. But saying no cannot be construed as “attachment” to the current system, and certainly not opposition to Medicare-for-all. Hacker’s claim to the contrary is equivalent to saying prisoners in a gulag are “stubbornly attached” to gulag food because they told a pollster they would object to being given less of it. (This question and the responses were emailed to me by the Roper Center for Public Opinion Research at the University of Connecticut.)
The other poll Hacker refers to – a Zogby poll – misled respondents. The poll, conducted June 18-21 2003, asked if “seniors should have the option of picking a private health plan approved by the Medicare program to provide their health benefits.” But the poll failed to ask respondents if they would feel the same way if they knew that allowing insurance companies to insure Medicare beneficiaries raises the cost of the entire Medicare program. This is a very well documented fact; every expert knows it to be true. Even Hacker and Schlesinger acknowledged it. How far support would have fallen had respondents been informed that their taxes would have to go up to give seniors the privilege of leaving the traditional Medicare program and enrolling with an insurance company? We don’t know. Zogby didn’t ask, possibly because the conservative Galen Institute was the sponsor of the poll.
Now for Hacker’s and Schlesinger’s claim that Americans are afraid of a government-financed single-payer. This claim relied primarily on two polls conducted over several decades: the “General Social Survey,” conducted by the University of Chicago, and the “National Election Studies” survey conducted by the University of Michigan.
Hacker and Schlesinger claimed the General Social Survey supported the following baffling statement:
“[W]hile approximately 80 percent of the public endorses some collective responsibility for health care finance, support for a completely collective role rarely garners majority support and, if so, then for only brief periods of time (see Figure 1)” (page 252).
What does “some collective responsibility” mean? How does it differ from “complete collective responsibility”? The latter seems to mean government pays for 100 percent of the national health care bill. But no country in the entire world does that. What does “health care finance” refer to? Universal coverage? Less-than-universal coverage? A single-payer system? The current multiple-payer system?
The figure Hacker and Schlesinger refer to as evidence for this baffling statement is a bar chart, based on the General Social Survey, showing bars for various years broken down by the proportion of the populace who support “collective,” “individual,” and “split responsibility for medical care.” The figure indicates that from 1975 through 2000 roughly 50 percent of Americans supported “collective responsibility,” 30 percent supported “split responsibility,” and 20 percent supported “individual responsibility.” How any reasonable person can conclude from these data that Americans oppose single-payer because they fear government and value choice of health insurance company is beyond me. If we really must ask whether such ambiguous data dictate that we abandon or support a Medicare-for-all system, it would seem more reasonable to interpret these data to say a majority of the public will support Medicare-for-all.
To enhance your impression of how flimsy this bar chart is, consider the actual question asked by the GSS survey:
In general, some people think that it is the responsibility of the government in Washington to see to it that people have help in paying for doctors and hospital bills. Others think that these matters are not the responsibility of the-federal government and that people should take care of these things themselves. Where would you place yourself on this scale [respondents were handed a card showing numbers running horizontally from 1 to 5], or haven’t you made up your mind on this?
Above number 1 on the card is the label, “I strongly agree it is the responsibility of government to help” and above number 5 is the label, “I strongly agree people should take care of themselves.”
Similarly, Hacker and Schlesinger use data from the National Election Studies survey that is at best ambiguous and at worst (from Hacker’s point of view) favorable to single-payer to spin a picture of Americans so “deeply divided” about the role of government that single-payer isn’t possible. They claim that a single question from this survey supports the following conclusions:
“Americans have long been deeply divided about their preferred approach to expanding health insurance…. Americans … split evenly between those who favor administration of insurance benefits by the government and those who prefer subsidies for private insurers (table 2)” (page 255).
The table they refer to shows that over the last half century roughly 45 percent favor “government insurance” versus about 40 percent for “private insurance.” Here is the question:
Some people feel there should be a government insurance plan which would cover all medical and hospital expenses for everyone. Others feel that all medical expenses should be paid by individuals, and through private insurance plans like Blue Cross and some other company paid plans. Where would you place yourself on [a seven-point] scale…. ?
There was, of course, no other information to help respondents interpret the key phrases in this question including “government insurance plan.” Respondents had to rank themselves as a “1” if they were strongly in favor of a “government insurance plan” that paid all expenses for everyone, and 7 if they felt strongly in favor of “individuals and private insurance plans” paying some unspecified portion of expenses, or some number in between if they felt less than strongly about their opinion. Hacker and Schlesinger treated everyone who ranked themselves as a 4 as undecided, and then treated all the 1, 2, and 3 people as for “government” and all the 5, 6, and 7 people as for “private insurance.”
Even if we didn’t know that Hacker was an avid proponent of the “politics, politics, politics” mantra, and that this mantra amounts to little more than an excuse to make policy decisions based upon ambiguous and cherry-picked polling data, we might reach these conclusions simply by reading the two papers by Hacker I have reviewed here. In his 2006 article for Slate, and his 2007 paper for the Journal of Health Politics, Policy and Law, Hacker urged his readers to abandon single-payer based on poll results that were not merely cherry-picked (with one unintended exception he excluded polls that showed two-thirds support for single-payer), but, even after careful cherry-picking, were still unclear in their implications.
I am not saying polling data reveal that only a single-payer system attracts majority support. A fair reading of the polls (although not the citizen jury results) suggests that Americans would accept a variety of solutions to the health care crisis if they could be convinced that they would cover everyone and bring costs down.
I strongly disagree with Hacker, however, that the polling data demonstrates a majority wants to defend the current employer-based multiple-payer system and oppose a single-payer system. And I strongly disagree with the assumption that people who care about solving the health care crisis should examine polls first and then decide how to solve the health care crisis. If we must put our finger in the wind before we decide whether to support single-payer, then let us at least consult research that used rigorous methodology, e.g., the citizen juries, and polls that inform their respondents about actual proposals. Let us not consult polls that use vague phrases like “people should take care of these things themselves.”
Appendix: Abstract of one of two papers Hacker misrepresented
In his paper with Mark Schlesinger published in the Journal of Health Politics, Policy and Law in 2007, Hacker cited two papers for support of this sentence: “Americans embrace choice of insurance not because they favor markets in health care per se but because they have so little trust in government, employers, or private insurance and want protection against problematic experiences.” Neither paper discussed lack of trust in government or employers. Both papers were about public hostility to the insurance industry. Below I present the abstract of one of the two papers (there was no abstract for the second one).
This paper examines the depth and breadth of the public backlash against managed care and the reasons for it. We conclude that the backlash is real and influenced by at least two principal factors: (1) A significant proportion of Americans report problems with managed care plans; and (2) the public perceives threatening and dramatic events in managed care that have been experienced by just a few. In addition, public concern is driven by fear that regardless of how well their plans perform today, care might not be available or paid for when they are very sick. (Robert Blendon et al., “Understanding the managed care backlash,” Health Affairs 1998;17(4):80-94))
Stay tuned for Part 5: Celinda Lake’s “research” for the Herndon Alliance
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Taming the Deficit
Saving Our Children from Themselves
By David Rosnick and Dean Baker
Center for Economic and Policy Research (CEPR)
Understanding the Deficit
One of the most popular causes among Washington political insiders is reducing the budget deficit. The conventional story in these circles is that current and projected future deficits will place an unbearable burden on future generations. Their argument is that the need to reduce the deficit is a question of intergenerational equity.
The leading spokespeople for this position, such as David Walker, the President of the Peter G. Peterson Foundation, often refer to the country’s $62.1 trillion “real federal financial hole.”
However, it seems that very few people have a clear understanding of this debt figure. This figure is not in any way a measure of money transferred from younger generations to older generations. In fact, rather than being a measure of how much debt older generations will pass on to today’s young people, to a large extent this ominous debt figure is actually a measure of the debt that today’s young people are projected to run up given the current structure of existing programs, most importantly Medicare. In other words, the huge debt numbers that are being used to scare the country – especially the young – are largely projections of how much debt today’s young will pass onto future generations.
The Cause of the Projected Debt
There are two reasons why later-age cohorts are projected to add more to the debt than the generations that preceded them. First, life expectancy is increasing decade by decade and is projected to continue to do so. Life expectancy after age 65 is currently 18.9 years. It is projected to be 23.2 years in 2085. If the tax and benefit formulas for Social Security and Medicare remain unchanged, then the benefits received in these programs will rise through time, as workers collect benefits for a longer period of time.
However, increasing longevity is a relatively minor factor in the rising deficit projections. The main factor is that per person health care costs are projected to far outpace the rate of per capita GDP growth. In other words, the main reason that today’s young and those yet to be born are projected to impose a far larger burden on the government than their parents and grandparents is that their health care is projected to be far more costly.
If the United States had health care costs that were in line with those of other wealthy countries, then the projections would show enormous surpluses, not deficits. Figure 3 shows long-term budget projections for the United States and then adjusts these projections under the assumption that it has the same per capita health care costs of Germany, Canada, Spain, and the United Kingdom.
As can be seen in all of these cases, the United States is projected to run enormous surpluses. For example, if the United States had the same per capita health care costs as Canada, its budget surplus would be equal to 0.13 percent of GDP by 2050. By 2080, its budget surplus would be 2.52 percent of GDP. In short, the budget problem facing the United States is almost entirely an issue of dealing with an out of control health care system, not the old stealing from the young.
It has been said the the profligacy of our boomer generation, in wanting to keep our Medicare and Social Security benefits, is resulting in an intergenerational transfer that will drown our children and grandchildren in debt racked up by the tsunami of federal budget deficits caused by these two programs.
The potential is very real, but the framing is flat out wrong because it leads to advocacy of policies that could not be more damaging: cut Social Security benefits and make even deeper cuts in Medicare benefits.
Social Security is not a problem. The program requires little more than a few tweaks to make it solvent forever.
Medicare is the problem, but it is not due to our overuse of health care services. Our level of use is comparable to other nations. It is the outrageous rate of health care inflation that is the driving force that will create intolerable deficits in the future. We do not need to eliminate beneficial health care services. We need only to tame health care inflation, just as every other nation has already done by adopting some form of social insurance.
Because we are way behind schedule, with health care inflation already taking a heavy toll, we should not accept the less efficient models of social insurance but instead try to make up with a more efficient version – a single payer Medicare for all.
This report should be downloaded since it is invaluable as a resource to educate others. In fact, right now click on the link and quickly look at Figure 3 (cited above). That alone should motivate you to retain this report and share it with others.
We do have an obligation to our children and grandchildren, though it is not in declining the intergenerational transfer to finance our programs that provide us with security in retirement. Our obligation is to create and transfer to them a health care financing program that will ensure that they always will have the security of health care without the insecurity of mounting debt to pay for it. We need to transfer to our progeny a financing system which will save them from THEIR deficit.
By Gabe Bullard
WFPL News, December 10, 2009
KY- About ten area residents gathered in Louisville Thursday to voice support for a single-payer health care plan.
Many of the same demonstrators have held similar protests in the last few months. This particular demonstration was one of about 20 held across the country to mark Human Rights Day.
The protestors are unhappy with the compromises many Democrats have made to the current healthcare overhaul proposal. Harriette Sieler is the secretary of Kentuckians for Single-Payer Healthcare. She says she’s also not happy with the debate surrounding the legislation.
“Right now in Congress they are saying the eligibility age of Medicare to 55,” she says. “I say lower it to zero.”
The group gathered outside of Senator Mitch McConnell’s office downtown.
Dr. Garrett Adams with Physicians for a National Health Program took issue with Senator McConnell’s recent statement that he hasn’t heard from any Kentucky doctors who support the healthcare overhaul.
“Mr. McConnell’s statement is not correct,” he says. “The facts belie his statement that physicians do not support national healthcare, because they do.”
McConnell is among the proposal’s opponents. He says, among other things, the plan would be too expensive.
New Report Highlights Medicare Advantage Insurers’ Higher Administrative Spending
Committee on Energy and Commerce
U.S. House of Representatives
December 9, 2009
Today Energy and Commerce Committee Chairman Henry A. Waxman and Oversight and Investigations Subcommittee Chairman Bart Stupak released a new report which found that 34 Medicare Advantage insurers expend significant sums on profits, marketing, and other corporate expenses.
The report found:
From 2005 through 2008, the average Medicare Advantage insurer spent over 15% of premium revenue on profits, marketing, and other corporate expenses. Two-thirds of the Medicare Advantage insurers surveyed by the Committee had a medical loss ratio below 85% during at least one of the four years examined. Six of the insurers had medical loss ratios below 75% in one or more years. In comparison, traditional Medicare spends less than 1.5% on administrative expenses and over 98% on health care. In the aggregate, the Medicare Advantage insurers spent $1,450 per beneficiary in 2008 on profits, marketing, and other corporate expenses, nearly ten times as much as traditional Medicare spent on administrative expenses per beneficiary.
Requiring all Medicare Advantage insurers to have a medical loss ratio of 85% would provide billions of dollars in additional medical services to seniors. The total amount spent on profits, marketing, and other expenses by Medicare Advantage insurers over the last four years was $27 billion. The House health care reform bill requires Medicare Advantage plans to spend at least 85% of their total premium revenues on medical claims. If this threshold had been in effect from 2005 through 2008, the Medicare Advantage insurers would have spent an additional $3 billion on their beneficiaries’ medical care, enough to eliminate all copays for preventive care for all Medicare beneficiaries for ten years.
In 2007 and 2008, Medicare Advantage insurers with medical loss ratios lower than 85% paid their executives over $1.2 billion. In 2007, a company that had a medical loss ratio of 79% paid an executive over $35 million. The same company paid 16 more executives salaries and bonuses worth $1 million or more. Another company with a medical loss ratio of 79% paid more than $210 million in compensation to 260 executives.
Medicare Advantage insurers have spent millions on expensive retreats. In 2007, one company with a medical loss ratio of 83% spent $3.1 million for two events in Hawaii. In 2007, a company with a medical loss ratio of 84% spent $2.5 million on employees and agents at a retreat in San Jose del Cabo, Mexico and $1.4 million on an event in Rome, Italy. In 2008, a company with a medical loss ratio of 82% spent $1.5 million on a meeting in Edinburgh, Scotland and $1.8 million on a trip to Cancun, Mexico.
Congress and the Obama administration decided up front that reform would be based on private insurance plans, rejecting without consideration the single payer Medicare for all model.
They are proposing innovative pilot programs as experiments in containing health care costs, glossing over the logistical nightmares and the lack of a foundation in policy science, as they move forward with these untested policies. Yet they have right in front of them one of the most important, most expensive, and most credible real-life experiments ever conducted: contrasting the government Medicare model with the private Medicare Advantage insurance plans.
In comparing traditional Medicare with Medicare Advantage, we need to set aside from consideration the funds that are used to pay for actual health care since these are our funds merely held in trust for the payment of medical bills. What we need to compare are the costs of the administrative services that are being provided by each entity.
The experiment has been completed, and the results are in. The private Medicare Advantage insurers spend nearly ten times the amount per beneficiary that is used to administer the government Medicare program. TEN TIMES!
Some might say that we aren’t being fair because some of the ten fold increase in spending goes to profits and to expensive retreats for the private insurance executives, whereas the traditional Medicare program doesn’t have those obligations. In this instance, what’s fair in the business community is fraud in the government.
Congress has the results of this study. The report has been generated by one of its own committees. Our legislators have a fundamental moral obligation to study this crucial real-life experiment. They then need to act upon it instead of upon the magical thinking behind the nebulous pilot projects.
In fact, even this report contains one such flawed policy recommendation. They recommend that the private insurers be limited to 15 percent of the insurance pool to use for administration and profits. That is still about eight times the administrative costs of Medicare. EIGHT TIMES! Is that the best that Congress can come up with?
Medicare is already under attack for its perceived parsimoniousness. Since the pilot projects would be designed to further reduce spending within the Medicare program, that perception would be amplified, seriously threatening the support of the health care providers.
We first need the broad, solid infrastructure of single payer Medicare for all and only then should we consider new pilot projects that are based on sound policy science that would work for all of us, providing quality care while protecting our finances. The probability of getting the policies right would be much greater in a single system in which patients, providers and the government are all working together toward a common goal: quality, affordable health care for all.
There is something for those who disagree: a little vicarious serendipity. You can check out the brochures and websites of the expensive resorts, and then close your eyes, lean back and dream about the great time that the insurance executives are having with the money you paid them in the form of excessive insurance premiums. Pleasant dreams.
Two-thirds of Americans support Medicare-for-all (#3 of 6)
Informative polls show two-thirds support for single-payer
By Kip Sullivan, JD
In Part 2 of this six-part series, I reported on the results of two “citizen jury” experiments in which advocates for single-payer, managed competition, and high-deductible policies spoke to, and were questioned by, “juries” that were representative of America. In the case of the 1993 “jury” sponsored by the Jefferson Center, 71 percent voted for single-payer. In the case of the 1996 “jury,” 61 percent voted for single-payer when no specific information about its cost to individuals was presented, and 79 percent voted for a single-payer system that would have lowered premium and out-of-pocket costs by as much as taxes rose. Both juries rejected proposals relying on health insurance companies by huge majorities.
Many polls that ask about support for Medicare-for-all produce results that confirm the citizen jury findings. But others don’t. What explains that inconsistency?
The more they know about single-payer, the more they like it
In this paper (Part 3 in a six-part series) I will present data from polls that ask about single-payer, and then inquire why some polls show landslide majorities for single-payer and some do not. We will find a clear pattern: Polls that convey more information tend to report higher levels of support than polls that convey little information, and polls that convey accurate information tend to report more support than polls that convey inaccurate information.
Table 1 lists 14 poll questions taken from 11 polls conducted over the last two decades which used the phrase “single payer” and/or referred to an existing single-payer system (Medicare, for example). All 14 questions found majority support for single-payer.
Three of these polls (representing one question each) were limited to doctors. I have included these physician surveys to debunk the false impression (created primarily by the American Medical Association) that the average doctor is opposed to single-payer. The three polls shown in Table 1 indicate that support among doctors is about 60 percent.
Table 1 indicates that public support for single-payer ranges from a low of 50 percent to a high of 69 percent. I have divided the polls of the general public into those that found support levels at 60 percent or higher (eight questions) and those that found levels in the 50-to-58 percent range (three questions).
Table 1: Polls indicating majority support for single-payer
……………………………………………………………For single-payer……..Opposed to single-payer
General public: Polls in which support is 60 percent or higher
Harvard University/Harris (1988)(a)……………………61%…………..not asked
LA Times (1990)(b)…………………………………………….66%………….not asked
Wall Street Journal-NBC (1991)(c)……………………….69%…………….20%
Wash Post-ABC News (2003)(d)…………………………..62%………….not asked
Civil Society Institute (2004)(e)……………………………67%……………..27%
AP-Yahoo (2007)(f)……………………………………………..65%…………..not asked
Grove Insight (2009)(g)………………………………………64%……………..28%
Grove Insight (2009)(g)………………………………………60%……………..27%
General public: Polls in which support is below 60 percent
Kaiser Family Foundation (2009)(h)……………………..58%……………….38%
Kaiser Family Foundation (2009)(h)……………………..50%……………….44%
New Eng J Med (medical school faculty and students) (1999)
Arch Int Med (doctors) (2004)………………………………64%…………….not asked
Minnesota Med (doctors) (2007)……………………………64%…………….not asked
(a) The question asked by the Harvard University/Harris poll was described in the Health Affairs article reporting the results as follows: “The majority of Americans (61 percent) state they would prefer the Canadian system of national health insurance where ‘the government pays most of the cost of health care for everyone out of taxes and the government sets all fees charged by hospitals and doctors….’” An analogous question posed to Canadians found that only 3 percent of Canadians said they would prefer the American system.
(b) The question asked by the Los Angeles Times poll was: “In the Canadian system of national health insurance, the government pays most of the cost of health care out of taxes and the government sets all fees charged by doctors and hospitals. Under the Canadian system – which costs the taxpayers less than the American system – people can choose their own doctors and hospitals. On balance, would you prefer the Canadian system or the system we have here in the United States?” Sixty-six percent chose the Canadian system and 25 percent chose the US system.
(c) The question asked by the Wall Street Journal-NBC poll was: “Do you favor or oppose the US having a universal government-paid health care system like they have in Canada?”
(d) The Washington Post-ABC News poll asked: “Which would you prefer – (the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance); or (a universal health insurance program, in which everyone is covered under a program like Medicare that’s run by the government and financed by taxpayers?)” Thirty-three percent preferred the current system while 62 percent preferred the “universal system.”
(e) The Civil Society poll asked: “Other major nations, such as Canada and England, guarantee their citizens health insurance on the job, through government programs, or via a nonprofit source. Would it be a good or bad idea for the United States to adopt the same approach to providing health care to everyone?”
(f)The AP-Yahoo poll asked two questions. One asked respondents which of these two proposals they agreed with: (1) “The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers” (65 percent chose this option); (2) “The United States should continue the current health insurance system in which most people get their health insurance from private employers, but some people have no insurance” (34 percent chose this option). The second question was: “Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?” (54 percent said they were supporters of single-payer and 44 percent said they were opposed).
(g) The Grove Insight poll asked two questions. One asked: “Federal leaders are considering expanding Medicare to all Americans, so that people have another option besides private health insurance or an HMO. Do you favor or oppose the creation of this type of public health plan option?” (64 percent said they favor this proposal). A very similar question was asked which differed from the first by including information on the financing mechanism: “There is proposed federal legislation that gives any American, regardless of age, the option of joining the Medicare program. Americans who choose this option would share the cost of the coverage with their employer through increased Medicare payroll deductions, instead of paying private health insurance premiums. Do you favor or oppose this legislation?” (60 percent favored it and 27 percent opposed it). Both questions, especially the second one, imply private insurers will continue to exist alongside a Medicare program open to all. But the questions are so similar to questions that clearly ask about Medicare-for-all systems that I decided to include them here.
(h) The Kaiser Family Foundation poll asked: “Now I’m going to read you some different ways to increase the number of Americans covered by health insurance. As I read each one, please tell me whether you would favor it or oppose it.?” This was followed by eight proposals which, with the exception of the question about the “public option,” were asked in a random order (the “option” question was always asked at the end). Two of these questions asked about single-payer. The first read: “Having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for all.” Fifty-eight percent said they favored this proposal while 38 percent said they opposed. The second read: “Having a national health plan – or single-payer plan – in which all Americans would get their insurance from a single government plan.” Only 50 percent favored this proposal while 44 percent opposed.
For sources see Table 2 below.
If we examine the questions posed by all the polls of the general public, one difference between the two sets of poll questions jumps out immediately: The questions that generated levels of support at 60 percent or higher mentioned one of three existing single-payer programs – the Canadian system, the British system, and the US Medicare program. (I have bolded the words referring to these systems in the poll questions, which are presented in the footnotes to Table 1.) In other words, those questions didn’t just rely on the phrase “single payer,” a phrase most people do not understand.
On the other hand, the three questions that prompted support in the 50-to-58-percent range used the phrase “single-payer” but did not refer to an existing single-payer system or program. The second AP-Yahoo question, for example, merely asked respondents if they considered themselves to be “single-payer supporters.” Fifty-four percent said yes to that question, which was substantially below the 65 percent who indicated in the same AP-Yahoo poll that they supported a system of universal coverage “like Medicare.” These two AP-Yahoo questions taken together suggest that merely using the term “single-payer” and not comparing it to Medicare will cut roughly 10 percentage points off the support level for single-payer.
It might be argued that the second AP-Yahoo question shown in Table 1 produced a relatively low single-payer support rate (54 percent) because it also mentioned the words “taxpayers” and “government.” But that argument doesn’t work. All but one of the other questions that produced support levels of 60-percent or higher also mentioned “government” and “taxes.” The difference is they also mentioned an existing single-payer system or program.
Apples-to-aardvarks comparisons also reduce support for single-payer
The two questions in Table 1 posed by the 2009 Kaiser poll (see question 13, page 8), which showed 58 and 50 percent support for single-payer, reveal another factor that seems to influence poll results – a factor I’ll call the “line-up effect.” The Kaiser poll asked about single-payer as well as a half-dozen other proposals without indicating what effect each proposal would have on costs, the number of uninsured, and freedom to choose one’s doctor, to name just a few of the variables most people would be interested in. By contrast, the polls listed in the 60-percent-or-higher category did not present single-payer in a line-up with other proposals; they simply asked whether respondents would support a single-payer system, or they contrasted single-payer with the current system. The “line-up effect” generated by the Kaiser polls would be minimized or eliminated in a citizen jury experiment because the jury would have plenty of time to inquire about the relative effectiveness of the competing proposals. Respondents to polls don’t have that luxury.
The 2009 Kaiser poll began with this announcement:
Now I’m going to read you some different ways to increase the number of Americans covered by health insurance. As I read each one, please tell me whether you would favor it or oppose it.
Notice the phrase, “different ways to increase the number of Americans covered by health insurance.” It implies the “different ways” have all been shown by research to work, and perhaps to reach roughly similar results.
This question was then followed by a description of eight proposals, including “expanding Medicare to people between the ages of 55 to 64,” “offering tax credits to help people buy private health insurance,” and “requiring all Americans to have health insurance.”
This “line up” method of asking about support for single-payer is by no means fatal, but it does appear to reduce the pro-single-payer response rate by somewhere in the range of 5 to 10 percentage points. The Kaiser question that produced 58 percent support asked about “having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for all.” Because this question did not mention taxes and government, you might think more than 58 percent of Americans would have said they favored this proposal. After all, when other polls that do not put single-payer in a line-up but do compare single-payer to Medicare and do mention “government” and “taxes” (see the upper half of Table 1), more than 60 percent indicate their support. The fact that only 58 percent of Americans responded favorably to this question from Kaiser – a question that does mention Medicare but mentions neither “taxes” nor “government” – begs for an explanation. It is reasonable to hypothesize that the explanation is the “line up” context in which the question was asked.
The second Kaiser question listed in Table 1, the one that produced only 50 percent support, contained a double whammy. Like the first Kaiser question, it used the line-up method; unlike the first question, it failed to compare single-payer with Medicare or another single-payer system. This suggests that the cumulative effect of the line-up method plus failure to compare single-payer to Medicare can diminish support for single-payer by about 15 percent.
Perhaps an analogy will help. Imagine if you were asked to indicate whether you “favored or opposed” six “ways to lose weight,” and the “ways” (“ways” is the noun Kaiser uses) ranged from the truly effective (for example, exercising for half an hour a day) to the barely effective (for example, weight loss pills or drinking more water). Imagine furthermore that the pollster gave you no information at all on the effectiveness of the various “ways” nor on their side effects. It seems likely that many respondents could be lulled into thinking all the “ways” are roughly equivalent in effectiveness and that respondents would, therefore, give less support to the effective methods of weight loss in response to this type of “line up” question than they would if they were simply asked, “Do you support exercise as a means of weight loss?”
Let me offer one more example of the use of the line-up method in a poll about health care reform, this one the July 2009 poll by Time Magazine. Time posed questions about seven different proposals that began with the phrase, “Would you favor or oppose a health care bill that…?” The implication of the phrase “a health care bill” is that members of Congress and experts in general think all of the proposals the respondent is about to hear will ameliorate the health care crisis to some degree, perhaps to the same degree. The single-payer question read:
Would you favor or oppose a health care bill that creates a national single-payer plan similar to Medicare for all, in which the government would provide health care insurance to all Americans?
Forty-nine percent favored single-payer, 46 percent opposed it. Like all the poll questions shown in Table 1 that showed support for single-payer in the 60-to-70-percent range, the Time question mentioned Medicare and “government.” (Oddly, unlike the high-scoring poll questions in Table 1, the Time question didn’t mention “taxes.”) You might think, then, that the Time poll would have produced a level of support for single-payer in the sixties. The fact that it produced only a 49 percent “favor” rating suggests, again, that something about the “line up” format reduces support for single-payer by about 10 percentage points.
To sum up this section: Polls that ask reasonably informative questions about single-payer show that somewhere between 60 and 70 percent of Americans support single-payer. This level of support can be reduced into the 50-to-60 percent range by two methods: Asking about “single-payer” without comparing single-payer to Medicare or the systems of Canada or the UK; and inserting the question about single-payer in a list of a half-dozen other proposals without warning respondents that the non-single-payer proposals, especially incremental proposals like tax credits, will have effects that are quite different from the single-payer proposal.
Two more examples of polls that convey too little information
To explore further the hypothesis that vagueness in poll questions diminishes support for single-payer, consider polls that are even vaguer than the polls in Table 1 that use “single payer” but offer almost no details about it. Let’s examine three polls that did not use the phrase “single payer” and offered no details about how the proposed “government” program would work.
In Part 2 of this series, I described a CBS poll conducted in June and August 2009 which asked:
Do you think the government would do a better or worse job than private insurance companies in providing medical coverage?
This question has the ring of a single-payer question, but it leaves numerous important questions unanswered, including whether the program in question would provide coverage to everyone and whether “provide” means cover people directly or give them subsidies so they can buy coverage from insurance companies.
We saw that when this question was asked in June 2009, 50 percent said “the government” would do a better job, but when this question was asked in late August 2009, only 36 percent said “the government” would do a better job. Does this CBS poll contradict the more precise polls listed in Table 1 that found two-thirds support for single-payer?
The answer is no. The CBS poll conveys so little information about how “the government” would do the “job” of “providing medical coverage” that it isn’t even clear if this question was meant to be about single-payer. In the context of the current debate, Americans are much more likely to think the question refers to the Democrats’ 2009 “reform” bills, which require Americans to buy health insurance from insurance companies, than to single-payer legislation. The sharp drop in support for “the government” in the CBS poll between June and August is evidence that the highly publicized town hall meetings held in August to discuss the Democrats’ bills influenced responses to the poll, which in turn indicates many respondents thought the question was about the Democrats’ legislation, not HR 676 (the single-payer bill introduced in the House of Representatives) or S 703 (the Senate single-payer bill).
We see a similar problem in the following question, contained in both a CBS/New York Times poll and a Harvard School of Public Health poll, conducted over several decades:
Do you favor or oppose national health insurance, which would be financed by tax money, paying for most forms of health care?
Like the phrase “government providing medical coverage” in the CBS poll, the phrase “national health insurance” in this poll could mean government financing of universal coverage through a single-payer system or through a multiple-payer system. If you look at Exhibit 1 on page 35 of this article from Health Affairs, you’ll see that between 1980 and 2000 the percent of respondents saying they favor “national health insurance” ranged between 46 and 66 percent. The vagueness of the phrase was unquestionably a significant reason why support fluctuated so much.
Another way to diminish support for single-payer: Convey inaccurate information
In addition to conveying vague information about single-payer there is, of course, another time-tested method of diminishing support for it, and that is to convey inaccurate information about it. This can be done explicitly and implicitly. It can be done explicitly by, for example, asserting in the question that single-payer systems raise taxes but do not lower premium payments and out-of-pocket costs. We have already seen one example of how reducing support for single-payer with inaccurate information can be done implicitly – by inserting the single-payer question into the middle of several other proposals, including incremental proposals such as tax credits for small employers, without warning respondents that the proposals have very different benefits and side effects.
Since 2001, the Gallup poll has been asking this explicitly misleading question (apparently each November):
Which of the following approaches for providing health care in the United States would you prefer: replacing the current health care system with a new government-run health care system, or maintaining the current system based mostly on private health insurance? (emphasis added)
“Government-run health care system” has garnered somewhere between 32 and 41 percent support since 2001 (while keeping the “current system” has attracted the support of 48 to 63 percent). But this poll is so biased it is irrelevant to the current debate. The problem here is the use of the phrase “health care” three times instead of “health insurance.”
The government does not “run health care” under single-payer systems (or any other system currently under debate in the US, for that matter). Under single-payer systems, clinics, hospitals, and makers of drugs and equipment that are privately owned today would remain in private hands. What the government will “run” in a Medicare-for-all system is health insurance, not health care. The latter phrasing conjures up nightmares of a gigantic government HMO in which the federal HMO owns all the clinics and hospitals and government bureaucrats decide whether you may have the surgery you and your doctor think you need or whether you must take Lipitor when your doctor prescribed Crestor.
I will discuss another example of a poll that delivers explicit misinformation in Part 5 when I discuss the “research” Celinda Lake did for the “option” movement.
The Bermuda Triangle
Finally, there is the occasional outlier poll that produces very low favorability ratings for single-payer about which I can only offer a plausible hypothesis. The August 7-8, 2009 Rasmussen Poll (not shown in Table 1) is an example. The poll asked:
Do you favor or oppose a single payer health care system where the federal government provides coverage for everyone?
We would expect this poll to produce “favor” responses below the 60-percent level because it offers so little information about what a single-payer is (it doesn’t mention Medicare or the Canadian or British systems, and offers no other details). But Rasmussen reported that only 32 percent supported single-payer while 57 percent opposed it. This question was not asked as part of a “line up,” so the line-up explanation doesn’t help us here. The two explanations that occur to me are sloppiness and deliberate manipulation of the process (for example, sampling a lot more conservatives than liberals). That possibility has occurred to others as well. Rasmussen’s non-electoral polls seem to show more support for conservative positions than other polls.
We have now reviewed three categories of polls that correspond roughly to support levels of 60 to 70 percent, 50 to 60 percent, and below 50 percent. Polls that produce greater-than-60-percent levels of support for single payer not only use the phrase “single-payer” but compare the concept to an existing single-payer program, typically Medicare. Polls showing 50 to 60 percent support inquire about “single payer” without comparing the concept to Medicare or to the single-payer systems of other countries or they pose the question about single-payer in a line-up context. Polls that seem to ask about single-payer and which show less than 50 percent support use phrasing that is so vague respondents cannot know whether the program being asked about is a single-payer and, if so, how it would work.
We saw in Part 2 of this series that two citizen juries conducted in the 1990s produced landslide votes for single-payer – votes equal to roughly 60 to 80 percent of all the participating “jurors.” These lengthy “jury” experiments are far more reliable than any poll could possibly be. And yet some polls confirm the “jury” experiments and some don’t. If we ask why, the answer is the polls that show support in at least the 60-to-70-percent range use the phrase “single payer” and give respondents concrete examples of single-payer programs.
If we couple the “jury” experiments with the polling data reviewed in this part, we see a pattern: The more people know about single-payer, the more likely they are to support it. We see this pattern when we compare the “jury” results with poll results, and we see it when we compare polls that show high levels of support for single-payer with those that don’t.
Stay tuned for Part 4: “Jacob Hacker’s ambiguous polls”
Table 2: Sources
Harvard/Harris poll: Robert J. Blendon et al., “Views on health care: Public opinion in three nations,” Health Affairs, Spring 1989;8(1)149-157.
Los Angeles Times poll: “Health Care in the United States,” Poll no. 212, Storrs, Conn.: Roper Center for Public Opinion Research, March 1990, cited in Robert J. Blendon et al., “Satisfaction with health systems in ten nations,” Health Affairs, Summer 1990;9(2): 185-192. Actual wording of the question is available at American Public Opinion Index, 1990, p. 649.
Wall Street Journal-NBC poll: Michael McQueen, “Voters, sick of the current health –care systems, want federal government to prescribe remedy,” Wall Street Journal, June 28, 1991, A4 (question available here).
New England Journal of Medicine poll: Steven R. Simon et al., “Views of managed care: A survey of students, residents, faculty, and deans of medical schools in the United States,” New England Journal of Medicine 1999; 340:928-936, 929.
Washington Post-ABC News Poll: Health Care, October 20, 2003.
Archives of Internal Medicine poll: Danny McCormick et al., “Single-payer national health insurance: Physicians’ views,” Archives of Internal Medicine 2004;164:300-304.
Civil Society Institute poll: Opinion Research Corporation, Americans and Health Care Reform: How Access and Affordability are Shaping Views, September 15, 2004.
Minnesota Medicine poll: Joel Albers et al, “Single-payer, health savings accounts, or managed care? Minnesota physicians’ perspectives,” Minnesota Medicine, February 2007:36-40.
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