In April 2019 Senate Majority Leader Mitch McConnell was the guest speaker at the American Hospital Association conference. He fiercely attacked Medicare for All with his battle cry: "Medicare for none," to enthusiastic applause.
Although McConnell saw little need to buttress his rallying call with statistical support for this receptive audience, these days politicians and pundits who oppose Medicare for All, or any single-payer proposal, have been citing the results of a 2018 survey sponsored by America's Health Insurance Plans(AHIP). And cite it they do as received wisdom--at every available opportunity because the survey reported that 71 percent of workers are satisfied with their employer-provided health plans underwritten by private insurance companies. Opponents of Medicare for All ask, "Why then should we take away private insurance and replace it with a government-run program?"
Why indeed? But what if that 71 percent were a false figure, created by research that is scientifically unsound? If it were true that employer-provided health plans were the gold standard, then we shouldn't force employees to give them up even if it were for the greater good of supporting healthcare for the entire U.S. population.
But are employer-provided health plans the gold standard? Is it true that most people--71 percent--are satisfied with their coverage? To answer that question we must look into the credibility of the survey, which those who have taken it at face value have not done.
First, Big Red Flag: Writing in Salon on June 22, 2019, pediatrician Dr. Sanjeev Sriram, a proponent of "health justice" raised suspicion about the AHIP survey--and for good a reason. AHIP, the sponsor of the survey, is an advocacy group for the insurance industry, as stated on their website: "Advocating for the health insurance community and the consumers they serve."And Luntz Global Partners, which conducted the survey for AHIP, was founded by conservative pollster Frank Luntz, who is a Trump White House insider and a Fox News commentator. Should we then be surprised that in a statement submitted to a House Rules Committee hearing on the Medicare for all Act of 2019 AHIP took a strong oppositional stance? In fact, AHIP has a long history of promoting private health insurance. In 2009 a spokesperson for AHIP told conservative commentator Lou Dobbs on CNN that "every survey shows strong satisfaction for private health insurance." Although challenged by other reports, this was the organization's mantra in its persistent resistance to healthcare reform.
Another glaring red flag is the sample size of one thousand respondents that according to AHIP represents the 180 million Americans whose "access to healthcare and coverage comes from a partnership between employers and health insurance providers." The sample size is woefully inadequate to represent the huge diverse population of workers that includes differences in age, sex, marital status, ethnicity, education, religion, political affiliation, residency (region, urban, suburban, rural), types of employment (skilled, unskilled, office, manufacturing, technical, technology-related), and health status. Unfortunately, we don't know the makeup of the sample since AHIP has not provided that information.
Perhaps the most critical issue: How was the online survey which was conducted over four days. (January 25-28, 2018) carried out. According to the National Science Foundation, e-mail surveys are increasingly unreliable: "The future of surveys as a reliable means to measure trends is in doubt. The response rates for surveys have been declining. E-mail surveys, touted as being convenient, have shown significant sample bias and non-response problems." What was the target population that produced the 1000 who responded? How many were contacted and what was the response rate? How many completed all the questions? How many did not or submitted answers to some questions? Was there a selection process or was anyone in a general population who responded included in the sample? It's difficult to imagine that the one thousand who chose to respond to over 40 questions represented the broad demographics of the working population? Yet, detailed information about the methodology of the survey and the composition of the sample that responded was not reported, But that information is essential for evaluating the credibility of the survey.
What about the age range of the sample, which is listed as ages 18+? How much "plus" is critical. Older workers with greater medical issues are likely to have different views on healthcare satisfaction than younger workers. Punctuating this point, a 2015 survey of millennials (ages 22-37 at the time of the survey), who are notorious for avoiding doctors, showed that 91 percent avoided making medical appointments and 51 percent admitted seeing a doctor less than once a year. If you don't use medical services you are likely to say you are satisfied with your healthcare coverage--any healthcare coverage. Unfortunately, the survey report does not give the age distribution within the sample.
And what is the degree of satisfaction for those with serious medical conditions and chronic diseases that may require extensive treatments? Surely older workers would have more complex assessments of their healthcare coverage. That's why it's important for the survey to report the full age range of the sample and the numbers in each decade--not just a breakdown of responses to questions for those subjects under age 41 and above age 41.
High wage earners in the upper fifth of the wage scale are likely to be more satisfied with their employer-provided health plans than wage earners in the lower fifth since they receive as much as nine times more benefits, reports economist Ed Dolan. Obviously, it's essential to know the wage levels of the respondents in the AHIP survey to see if all wage levels were included and equally distributed. But that information is not provided.
Then there's the issue of the survey questions. Are they worded to elicit accurate information or are they stacked to get desired responses?
The main question in the survey has been widely quoted: "Overall, how satisfied or dissatisfied are you with your current health insurance plan?" 71 percent said satisfied, 9 percent neither satisfied or dissatisfied and 19 percent dissatisfied.
Confounding the meaning of "satisfaction" is the response to another survey question that was not prominently reported. To the question "What is the main reason you personally do NOT feel satisfied with your current health insurance plan?" 82 percent answered, "Costs--I'm paying more and more every year but I seem to be getting less and less." How do we make sense of this? The responses to one question say 71 percent are satisfied with their employer-sponsored health plans and the responses to another question say 82 percent are dissatisfied? It's curious that AHIP's initial announcement of the findings of the survey reported the 71% satisfaction finding, which is the one the press, news anchors and commentators picked up, but not the 82% dissatisfaction finding.
For further clarification of the meaning of "satisfaction," the survey should have included questions about desired alternatives such as: "Would you prefer a plan with coverage that would remain in place if you lost your job, changed jobs, were unemployed or left to start your own business?"
The survey reported as a positive that 56 percent stay at their current jobs because of their health insurance. This may help businesses retain employees. But it's damaging for workers who may remain at an unsatisfying job out of fear of losing or changing their health insurance. It might also prevent some from taking the risk of leaving a job to start a business.