Public Split On What to Do About the Health Care System … News Release, Kaiser Family Foundation, February 25, 2016 The survey also finds that the words to describe such a [health care reform] plan clearly affect how people view it. For instance, nearly two-thirds (64%) of Americans say they have a positive reaction to the term “Medicare-for-all,” and most (57%) say the same about “guaranteed universal health coverage.” Fewer have a positive reaction to “single payer health insurance system” (44%). http://kff.org/global-health-policy/press-release/public-split-on-what-to-do-about-the-health-care-system-though-more-support-building-on-aca-than-repealing-it-replacing-with-a-gop-alternative-or-creating-a-single-payer-plan/ Kaiser Health Tracking Poll: December 17, 2015 By Bianca DiJulio, Jamie Firth, and Mollyann Brodie When asked their opinion, nearly 6 in 10 Americans (58 percent) say they favor the idea of Medicare-for-all, including 34 percent who say they strongly favor it. This is compared to 34 percent who say they oppose it. http://kff.org/uninsured/poll-finding/kaiser-health-tracking-poll-december-2015/

In 2009 I posted a paper on the PNHP website with the title, “Two-thirds of Americans support Medicare for all.” In that paper I examined two “citizen jury” experiments which reported support for single payer in the 70-to-80 percent range, as well as polls showing support in the 50-to-70 percent range. I showed that support for single payer rises as people are given more information about it.

Polls conducted since 2009 confirm that correlation. Two recent polls released by the Kaiser Family Foundation, one last December and one in February, illustrate the correlation. You can see it in these four questions reported by the two polls:

(1) 64 percent “have a positive reaction to the term ‘Medicare-for-all’” (February poll);

(2) 58 percent “favor … having a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for-all” (Dec.);

(3) 50 percent “favor … having guaranteed health insurance coverage … through a single government health plan” (Feb.); and

(4) 44 percent have a “positive reaction to ‘single-payer health insurance system’” (Feb). [1]

Questions 1 and 2 above – the questions that elicited the strongest support for single payer – used the phrase “Medicare-for-all.” Because Medicare has insured roughly a sixth of the U.S. population for a half century, Americans have a good idea how it works. “Medicare-for-all” thus communicates information to respondents about how a single payer works that phrases such as “national health insurance” and “single payer” do not.[2] Respondents to question 3 were given no such additional information about the “government plan” that would “guarantee coverage.” Question 4 offered no information at all about what a “single-payer system” is.

What would happen if Kaiser had provided information about single payer beyond the fact that it resembles Medicare? What if Kaiser informed respondents that single-payer systems lower total spending – taxes, premiums, and out-of-pocket expenses? Or what if Kaiser informed respondents that Medicare-for-all, or HR 676 (the national legislation supported by single-payer proponents in the U.S.), would restore patient choice of doctor as well as physician authority over medical decision-making? For some reason, pollsters can’t bring themselves to do that.

No poll has ever posed these questions: “Do you support or oppose a health insurance system in which everyone would be covered by a program like Medicare? Would your opinion change if you knew such a system would: Lower total spending on health care; restore patient choice of doctor; give doctors more control over medical decision-making?”

In fact, when pollsters have sought to determine how public opinion about Medicare-for-all can be influenced by information beyond that conveyed by the simple comparison to Medicare, they usually do the reverse – they convey inaccurate information. Kaiser is an example.

Although Kaiser has determined in previous polls that two-thirds of American adults say their support for a health policy proposal goes up if the proposal lowers costs and goes down if it reduces their choice of doctor [3], Kaiser has never posed a question about single payer which informed respondents that a single-payer system would cut total spending, restore patient choice of provider, or augment physician autonomy. In fact, Kaiser has done just the opposite.

In its February poll, Kaiser posed several follow-up questions to determine how certain assertions about universal coverage under “a single government health plan” would alter support or opposition for such a plan. But rather than ask all the respondents those follow-up questions, Kaiser asked only half. They asked the 50 percent who said they supported “a single government health plan” (see question 3 above) how they would feel if they heard “opponents” say taxes would go up (a half-truth) or “government” would gain “too much control over health care” (a lie). [4] Both questions cut support for “a single government health plan” by a whopping 40 percent – the initial 50 percent support fell to 30 percent when respondents heard the claim about taxes going up, and the 50 percent also fell to 30 percent when they heard the canard about “government” controlling “health care.”

Kaiser did ask questions containing accurate information about “a single government plan,” but only of the 43 percent who initially said they opposed “a single government plan.” Kaiser asked that 43 percent how they would feel if they heard that the “plan” would make “health insurance … a basic right,” “reduce health insurance administrative costs,” and eliminate premiums and out-of-pocket payments. Each question persuaded one-fourth of the initial opponents of the “plan” to become supporters.

So it is left to the readers to speculate what might have happened if Kaiser had bothered to ask its entire sample a question that compares single payer to Medicare, and then followed up with several accurate questions for its entire sample about cost (taxes and premiums and out-of-pocket costs, not just taxes) and provider choice. Let’s illustrate what might have happened if Kaiser had followed up with an accurate question about cost posed to its entire sample.

We know that 40 percent of the respondents to Kaiser’s February poll who initially expressed support for “a single government plan” became opponents when they heard “taxes” would go up. We know that one-fourth (26 percent) of the initial opponents in the February poll switched from opposition to support when they learned premiums and out-of-pocket costs would drop, and that one-fourth also become supporters when they heard administrative costs would drop. In short, somewhere between 25 and 40 percent of Kaiser’s total sample were movable with the cost information provided in that poll.

These figures indicate that support for a “single government plan” would rise above the 50 percent level reported in the February poll if all respondents had been told that the “government plan” would lower costs. By how much? A reasonable estimate is somewhere between 25 and 40 percent, and probably closer to 25 percent. If 25 percent is the correct estimate, that would put total support for single payer at 75 percent in Kaiser’s February poll.

Finally, let me ask this question: What would happen if Kaiser had used the phrase “Medicare for all” in its February poll (as it did in its December poll) rather than “single government plan,” and had asked a truthful follow-up question about cost? Would the total level of support have been even higher than 75 percent?

Notes

1. Kaiser’s February poll also posed a question asking respondents to evaluate four proposals, only one of which (“a single government plan”) was described as achieving universal coverage. The other three were repeal of the Affordable Care Act, replacement of the ACA with a “Republican-sponsored alternative,” and “build on the existing health care law.” Kaiser’s question asked which proposal “comes closest to your view of the future … system,” a question which I find rather odd. Kaiser reported, “[T]he largest share (36%) say lawmakers should build on the Affordable Care Act to improve affordability and access to care, while fewer choose establishing guaranteed coverage through a single government plan (24%), repealing the ACA and not replacing it (16%), or repealing the law and replacing it with a Republican alternative (13%).”

I would bet lots of money some pundit or reporter will claim, or has already claimed, that this poll “found” that only 24 percent of Americans support single payer. For several obvious reasons, that would be a false statement. Perhaps the most obvious reasons are that the question asked for their “viewpoint” on “the future” (not whether they support or oppose a particular proposal), and respondents were given four scenarios that conveyed virtually no information. A less obvious reason is that the question implied the three non-single-payer proposals achieved universal coverage.

2. It is understood by single-payer proponents, and presumably by most observers who use the phrase “Medicare for all,” that the comparison is to the traditional Medicare program, not Medicare Advantage. Previous Kaiser polls suggests the public thinks of Medicare as the traditional program, not as the privatized Medicare Advantage program. Obviously that might change some day if Congress and the White House continue to overpay the insurance companies that participate in Medicare Advantage and enrollment in Medicare Advantage continues to rise.

3. See questions 33a and b in Kaiser’s September 2009 tracking poll: 64 percent said they were “more likely” to “support” a proposal that cuts costs and 65 percent said they more likely to oppose a proposal if it limited their choice of doctor.

4. The statement that taxes will go up under a single-payer system is a half-truth; the other half of the truth is that premiums and out-of-pocket costs will decline, ultimately by more than taxes rose. The statement that “government will control health care” is false. The truth is just the opposite – physician and patient authority over medical decision-making that has been usurped by insurance companies over the last half century would be restored. If pollsters must ask respondents about “government control” over something, the true statement would be that government would control health insurance, not health care.

Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.