On October 1, 1996, I was one of three speakers who appeared before fourteen Minnesotans selected to participate in a "citizen forum" on healthcare reform sponsored by the Minneapolis Star Tribune and KTCA-TV, Minnesota's public television station. I made the case for a "single payer" healthcare system; the director of what was then called the HMO Council of Minnesota made the case for "managed competition"; and a third speaker made the case for "medical savings accounts" (MSAs). A single-payer system is one in which one payer (the government) reimburses doctors and hospitals. Managed competition is a theory that assumes that competition among HMOs can reduce healthcare costs without damaging quality of care. MSAs are traditional insurance policies with huge deductibles (typically $2,000 per person). After three and a half hours of discussion, eight of the fourteen citizens voted for single-payer, three voted for managed competition, one voted for a hybrid of single-payer and managed competition, and two abstained.
This vote strongly suggests that a sizable majority of Americans would support a single-payer solution to the healthcare crisis if they were ever exposed to a real debate about it. Other data support this conclusion. For example, a 1991 Harris poll found that 68 percent of Americans preferred Canada's single-payer healthcare system, compared with only 29 percent who favored the US system; a 1999 survey of professors and students at US medical colleges, reported in the New England Journal of Medicine, found 57 percent of students and faculty members of America's medical schools "thought that a single-payer system…was the best health care system," while only 22 percent were willing to say the same about managed care. But despite the public's preference for a single-payer system, and despite solid empirical evidence that single-payer would provide higher-quality care for less money than an HMO-dominated system, managed competition was elevated to de facto US health policy during the early 1990s, while single-payer proposals were kept off the public agenda by big business and its allies in Congress.
In California, the single-payer movement forced a debate–a very lopsided debate, as it turned out–about the single-payer proposal by collecting a million-plus signatures to put the proposal on the November 1994 California ballot. From July until Election Day, the anti-single-payer forces, led by the insurance industry, bought $11 million worth of radio and TV advertisements and financed a direct-mail campaign. Our "good neighbor," State Farm, spent close to a million dollars in October 1994 alone on letters personally signed by State Farm agents urging their customers to vote against the single-payer initiative.
The defeat of the single-payer proposal is one of three examples of corporate agenda-setting told by Barry Casper in an absorbing book titled Lost in Washington. Casper, a professor of physics at Carleton College during the years he wrote this book and, for the first eight months of 1991, Senator Paul Wellstone's policy adviser, also describes two other battles between public interest groups and wealthy special interests–the effort to defeat the National Energy Security Act, a bill promoted by the auto industry and the nuclear and fossil-fuel industries, and the battle for campaign finance reform.
Just as polls indicated a majority of Americans would support a single-payer program, so polls indicated majorities of Americans endorsed the positions the public interest groups took in the energy and campaign finance reform debates. Casper cites, for example, a 1991 poll showing that 86 percent of Americans supported increasing the average fuel efficiency of the nation's automobiles from 27.5 miles per gallon to 40 by the year 2000, a policy opposed by the auto industry and a substantial portion of Congress, including, notably, Senator Bennett Johnston, Democrat of Louisiana, then chairman of the Senate Energy and Natural Resources Committee. "We now have a political system in which a public policy proposal can have enormous popular support and the potential to garner an electoral majority," Casper concludes, "but it may not even get a fair hearing, much less a vote, in the Congress or anything approaching adequate coverage in the media."