Selling Single Payer Health Care to Voters: Last Time it Didn’t End Well
From a strategy point of view, the ‘Medicare for All’ movement is betting on the following:
One: That there is huge majority support in the U.S. to eliminate private health care and replace it with government run health care.
Two: That this support can withstand a relentless, and hugely financed campaign-for-existence by the health insurance industry, which will ask people how they would like getting their health care through the Department of Motor Vehicles.
Three: Or alternatively, even if the public does not support it, the massive heath care overhaul will still win approval by both houses of Congress and the President.
Fortunately history offers up a not too distant example of just such an effort. In 1994 a network of very serious health care organizations put together a quite serious California ballot initiative to enact a Single Payer health system, Proposition 186. It lost by a vote of 26% to 73% after a relentless NO campaign waged by some of the same private health insurers who will be leading the battle this time again.
Not long after that defeat I published The Initiative Cookbook, Recipes and Stories from Ballot Wars, which featured a brief debriefing afterwards with the leaders of the campaign, the journalists who covered it, and others. Here it is below, exactly as I wrote it in 1996. Anyone involved in the Medicare for All movement today would be foolish not to look at their experience and see what lessons it offers. I leave you to draw your own conclusions.
Proposition 186: The Decision to Put Health Care on the Ballot
[Excerpt from: The Initiative Cookbook, Recipes and Stories from Ballot Wars]
For almost a decade, starting in the mid-1980s, California health care activists went through the same debate before every election — should they try to take the issue of health care reform to the ballot. More than five million Californians were without health coverage. Many of those who did were being hit with rate hikes, policy cancellations and refused care when they got sick and needed their insurance. With leadership from a new consumer and labor coalition, Health Access, the reform movement gained speed, building the issue in the media and organizing behind reform efforts in the Legislature.
The reformers were no match however for the political clout of the mighty insurance industry. One camp, mostly made up of grassroots health activists, argued for taking the issue directly to the people with an initiative. Another camp, mostly made up of Capitol advocates, said, “show us the poll numbers that show we can win.” In fact the polls that were done suggested a health initiative to be a risky bet, and an expensive one that no one had the money to pay for. In 1988, 1990 and 1992 health care reformers let the initiative option slide.
Swept Up by the “Clinton Revolution”
The political chemistry of the health care issue turned overnight, with the 1992 election of Bill Clinton, who made reform of the health care system his number one priority. In California the reform movement was joined by Neighbor to Neighbor, which had led organizing drives opposing Reagan/Bush policy in Central America. In health care Neighbor to Neighbor saw a domestic issue they thought could tap a historic level of passion and activism. Says Executive Director Glenn Schneider, “we believed it would be at the level of the Vietnam War.”
In early 1993 Health Access set up a small committee, with Neighbor to Neighbor in the lead, to look at the viability of a 1994 initiative for “single payer” health care — a comprehensive approach to the left of the Clintons’ proposal in Washington. Other advocates focused on one last effort to push single payer through the Legislature. That summer a national Harris poll, asking general questions about health care, suggested 70% support for an approach loosely resembling single payer. In the fall initiative promoters agreed to a test of their capacity — raising $200,000.
What was to become Proposition 186 was originally written by Dr. Vishu Lingappa as a creative exercise. A member of the exploratory committee Dr. Lingappa remembers, “I wanted an actual stack of paper that I could wave around when we were giving talks.” In November 1993, with the reform effort stalled in Sacramento and compromised in Washington, and with $200,000 in pledges, Neighbor to Neighbor filed Lingappa’s draft with the Attorney General and launched the campaign.
“We thought the initiative was the only way to get single payer,” says Schneider. The campaign did no polling on its own, no testing of the initiative, the language or potential arguments. All the resources available were directed to the task of gathering the one million signatures needed to qualify for the ballot. “I mortgaged my house,” says Schneider.
The single payer campaign struck a chord with health care activists, who finally had a chance to take direct action. The campaign impressed both its friends and critics with the speed and enthusiasm of its volunteer signature gathering effort. Schneider and the initiative were featured on network television. Key unions also joined the effort. A leaders of the National Education Association told the campaign that if they could even win 40% of the vote it would thrust single payer into the national debate.
In July a Kaiser Family Foundation survey showed that only 29% of Californians had heard of the initiative and were split almost evenly (34% against, 38% for). However almost two thirds said the plan would be too much government involvement in their health care. By mid-October, after more than $5 million in anti-186 advertising by insurers, voter awareness of the initiative had leapt to 67% — with most dead set against it (50% against, 29% for). The final vote on election day was a wipeout (73% against, 27% for).
“The insurance industry basically beat Proposition 186 by flicking their finger,” says Sabin Russell who covered the campaign for the San Francisco Chronicle. Schneider argues that the initiative got caught in the unexpected storm of a historic rebellion against government in general. “For progressive folks this was the worst election in forty years. It was not a good time to be promoting government solutions.” Others believe, in retrospect, that the campaign didn’t take a hard enough look at political reality. “We were intoxicated, we believed our own bumper stickers,” says endorsements director Donald Cohen. Concedes Schneider, “I think we should have tested. It was a mistake not to do polling.”
The effects of Proposition 186’s lopsided defeat on the long term prospects for health reform are hotly debated. “Proposition 186 was a disaster for single payer,” says Russell of the Chronicle. “Because it was beat so decisively it set back the cause of single payer for years.” Donald Cohen says, “we allowed insurance companies the chance to advance the concept that government can’t do it — and that was a strategic mistake.”
Its leading proponents argue that Proposition 186 should also be judged by what it did to the cause of longer term movement building around the health care issue. “We built a list of 30,000 names,” says Schneider. “We built a base that sees this as a solution. Campaign Manager Paul Milne, says, “186 was run on the possibility not the likelihood of winning. Had 186 not been run the forces for health care would be far weaker than what they are today.”