Posted on December 11, 2008

Americans Support Single payer. Why Doesn't Celinda Lake?


Editor’s note:

Data derived from polls have long found strong support for “Medicare for All” or single payer national health insurance. For example, a recent AP/Yahoo poll found that 65 percent of Americans agree that the U.S. 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 taxpayer”. But so do other kinds of data, including data from citizen juries, focus groups, and even a national series of government-sponsored town hall meetings that were carefully designed to solicit support for anything but single payer.

In 2006, a Congressional Task Force created by the 2003 Medicare Modernization Act hosted 29 town hall meetings across the U.S. to ask Americans what type of health care reform they favored. The results of the “Citizen’s Health Care Working Group” were overwhelmingly in favor of single payer health insurance despite considerable bias against single payer health insurance in the way the meetings were structured. In fact, 25 of 29 of the meetings (86 percent) reported that a national health program was their most favored option (see press release and chart, “Congressional Task Force Disregards Public’s Call for National Health Insurance and chart,”).

Similar strong support for Medicare for All was found the last time health reform was on the top of the nation’s agenda, during the Clinton administration. In 1993, a citizen jury sat for 8 hours a day for five days in Washington, DC before making their choice among the then-leading options for health reform: managed competition (supported by Clinton), medical savings accounts, and single payer. Single payer received 17 out of 24 votes (70 percent). There were 5 votes for Clinton’s plan, and none for medical savings accounts. Focus groups conducted that year by Democratic pollster Celinda Lake reported the same strong support for single payer. “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 contrast, according to Lake, working Americans found the managed competition idea “laughable.” (“It’s Time for a Real Debate on National Health Insurance”)

So, how come Democratic pollster Celinda Lake now claims Americans won’t support single payer, and instead favor a plan that is a variant of managed competition? Because her latest research was brazenly biased. Kip Sullivan explains how and why.

An analysis of Celinda Lake’s slide show, “How to talk to voters about health care”

By Kip Sullivan
November 29, 2008

Summary of Lake’s conclusions

Did you know that the most effective way to promote universal health insurance is not to say “universal health insurance”? Did you know that when you feel the urge to say “universal health insurance” or “universal coverage,” you should check yourself and instead say, “quality, affordable health care”? That is just one of numerous controversial recommendations made by Celinda Lake, a pollster who now tours the country with a slide show entitled, “How to talk to voters about health care.”

You might think this advice comes from Sen. John McCain or other conservatives who don’t support universal health insurance. Conservative leaders much prefer the phrase “quality, affordable health care” because that phrase doesn’t convey a commitment to giving all Americans health insurance. In an article published last month, for example, Senator John McCain wrote that he stands for “quality, affordable health care for all Americans.”1 The 2004 Republican Platform states, “We will ensure … that Americans have access to quality, affordable health care.2 The president of the US Chamber of Commerce announced on January 8, 2008, “With practical solutions, we can also provide access to quality, affordable health care … for every American.”3 The Council for Affordable Health Insurance, a front group for the health insurance industry, asserts on its Web site, “One of the challenges that we as a nation face is the development of a health care system that enables all citizens to have access to affordable, quality health care.4 George W. Bush5 and Senator Norm Coleman (R-MN)6 are other examples of conservatives who prefer to say “quality, affordable health care.”

But Celinda Lake is no conservative. She was an advisor to Bill Clinton during his presidency. She has longstanding ties to Democrats and groups that support Democrats.7 So why does Lake recommend we tiptoe around the phrase “universal health insurance” or “universal coverage” and use instead a phrase beloved by conservatives? Lake’s explanation is that her research leads her to conclude that the majority of Americans are conservative, at least with respect to health care reform, and if health care reform is going to be achieved, health care reformers must use language that does not upset the average (conservative) American.

To give you an idea of how conservative Lake thinks Americans are, consider several other statements she makes in her public presentations. She tells her listeners that Americans think Medicare and Social Security “are frighteningly flawed programs,” and, therefore, Americans won’t support a Medicare-for-all system.8 She recommends activists and candidates say “American health care” (whatever that means) instead of “Medicare for all.” (For good measure, she warns against “a system like Social Security,” which is not a phrase anyone in the health care reform debate uses).9 She says Americans like their health insurance so much they will resist any proposal that threatens the health insurance industry.10 She says Americans get mad when our sick health care system is compared with the systems of other countries.11

One of the stranger statements Lake makes is that Americans don’t want “the undeserving” to have health insurance.12 According to Lake, average Americans even think their own parents fall into the category of “undeserving.” Here is how a colleague of Lake’s put it at a joint presentation with Lake:

Celinda did focus groups … where they would get people in the room, and they would ask them: “Do you support universal coverage for kids?” They would say, “Absolutely, that’s a moral issue.” Okay great. “Now, what about their parents?” “Uh-uh. Parents got to take care of themselves. In fact, there’s probably something wrong with those parents.…”13

Not surprisingly, Lake’s “findings” about American “values” lead her to recommend a solution to the health care crisis that does not resemble a Medicare-for-all (or single-payer) system. She recommends instead a system in which the insurance industry would continue to exist and a public program like Medicare would open offices around the country and begin to sell health insurance just as the private insurers do now. She says “competition” between the public program and the private insurers will bring down costs. She calls her proposal “guaranteed affordable choice.”

When Lake uses the word “choice,” she does not mean (and cannot mean) choice among doctors and hospitals and other providers of health care, the form of choice Americans care about. Any proposal that relies on the existing health insurance industry, which limits the providers patients may visit, cannot claim to restore to patients the freedom of choice they had prior to the managed care revolution of the 1980s. For Lake, “choice” means choice among health insurance companies, a form of choice about which Americans care little.

Lake’s research compared with other research

Lake’s assertions are either exaggerated or false. Her claims about Medicare and Social Security are unquestionably false. Medicare and Social Security are hugely popular programs. Politicians who threaten them are often said to be flirting with political death. Jacob Hacker, who developed the health care proposal Lake supports (see discussion below), describes Medicare as a “wildly popular program.”14 Moreover, polls indicate substantial majorities of Americans would support a system of universal health insurance based on Medicare. To take just two examples, a 2003 poll by ABC News and a 2007 poll by AP-Yahoo reported that over 60 percent of Americans would support a Medicare-for-all system. Here is the wording of the AP-Yahoo poll: “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.” Sixtyfive percent said yes to that question.15 By political standards, 65 percent is a landslide.

In her public statements and papers, Lake shows no interest in helping her audience understand research that conflicts with hers. She rarely discusses other people’s research, and when she does, it is in general and dismissive terms. Here is a rare example of a comment by Lake on conflicting research: “Voters support reform in principle, but I think many of us ask — when we see numbers that say that three-quarters or 85 percent of voters support this reform or that reform — well, where is the revolution?”16 The defect in this “logic” is obvious. Lake is saying we can reject a poll like the AP-Yahoo poll on the ground that, if the poll were accurate and two-thirds of Americans really do support a Medicare-for-all system, then “the revolution” would have already happened by now — America would already have a Medicare-for-all system. There is, of course, another very rational explanation for why polls might show huge public support for a policy that Congress refuses to enact, to wit, that in our money-drenched democracy powerful interests often thwart the public will.

If Lake were to say that a large majority of Americans support universal coverage and Medicare-for-all programs, and this support can be reduced by false propaganda against such programs, that would be an accurate diagnosis. (Of course, the reverse is also true. The current high level of support for Medicare-for-all can also be increased by a well-organized and well-financed campaign for a Medicare-for-all program.) But Lake doesn’t say this. Instead, she promotes the strange assumption that research that is inconsistent with hers has to be incorrect because “the revolution” has yet to materialize, and the absence of “the revolution” is prima facie evidence that most Americans harbor “values” that cause them not to support universal coverage or Medicare-for-all.

Why would Lake produce shoddy research and reach conclusions so hostile to Medicare and a Medicare-for-all solution, and so reassuring to the insurance industry? In the remainder of this paper, I address that question. I begin with an examination of the Herndon Alliance, the coalition that hired Lake to produce her odd findings.

Origin of the Herndon Alliance

The Herndon Alliance was formed in 2005 by groups and individuals who support universal health insurance but not through a single-payer or “Medicare for all” system. (Under a single-payer system, one public insurer replaces the nation’s 1,500 health insurance companies as the sole reimburser of doctors and hospitals. The one payer has the authority to set limits on what doctors, hospitals, and drug companies can charge.) Most of the individuals who founded or took leadership positions in the Herndon Alliance were enthusiastic supporters of Bill Clinton’s failed Health Security Act and similar proposals to achieve universal health insurance by funneling tax dollars to the insurance industry. Ron Pollack, director of Families USA and a founder of the Herndon Alliance, played a key role in convincing Clinton not to support a single-payer system at a meeting in Washginton, D.C. in 1991,17 and was perhaps the most visible proponent of Clinton’s bill outside of the White House after it was introduced in 1993.18 Richard Kirsch, director of Citizen Action of New York and an advocate of the Clinton bill, chaired the Herndon Alliance’s policy committee.19 Bob Crittenden, MD, the current director of the Herndon Alliance and a member of the board of Families USA, wrote a bill for the Washington State Legislature that Crittenden himself said was “strikingly similar” to Clinton’s Health Security Act.20 (Unlike Clinton’s bill, Crittenden’s bill actually passed, only to be repealed two years later.)

According to Crittenden, the original idea for the Herndon Alliance came out of a conversation he had with Gordon Bonnyman, another Families USA board member and an advocate of a program enacted by Tennessee in 1994 known as TennCare. Under TennCare, Tennessee privatized its Medicaid program literally overnight. In a 1996 article entitled, “Market-based Medicaid in Tennessee,” Bonnyman wrote of TennCare, “At the stroke of midnight on 1 January [1994], Tennessee moved all 800,000 Medicaid beneficiaries into managed care networks [that is, insurance companies].”21 When Tenncare predictably failed to contain costs, it underwent substantial cuts beginning in 2005.

According to Crittenden, about the time the TennCare cuts were being made, Bonnyman asked him why advocates of their particular brand of universal health insurance “keep losing.” This led to the formation of the Herndon Alliance. Here is how Crittenden recalled it:

[J]ust when the TennCare cuts were coming along, Gordon and I and Phil [“Phil” was not further identified] sat down one night and Gordon brought up the idea that we really can’t keep losing. On the verge of losing, he urged us to think differently and to think of ways we can win this and not lose. From that, we brought about 50 people together from about 50 different organizations and formed a thing called the Herndon Alliance.22

The founders of the Herndon Alliance (the group takes its name from the city where the first meeting was held) developed a unique explanation of why advocates of universal health insurance have yet to achieve universal coverage. Here is how Crittenden described the Alliance’s analysis:

So the question that came around … was: What can we do differently to be successful? When you’re doing the same thing, and you’re going backwards even though you’re winning little fights, what can you do differently? And … this group [that is, the founders of the Herndon Alliance] laid out the idea that we need to really contact or connect with the values that people hold in this country, we need to work with those values, and help them strengthen the values and connect the goals that they actually have values for supporting, and take those and help them support affordable health care for all Americans and for all people in America.

And from that we developed a work plan, how are we going to approach it to do some values research, which you’ll hear about today, and then to test that, to take it out in the field and say if we try focus groups, try polling, does it make sense.23

Although the language is vague (“if we try focus groups, try polling, does it make sense?”) and the syntax awkward (“connect the goals that they have values for supporting”), one can discern the Herndon Alliance’s explanation for why universal coverage advocates “keep losing.” The founders of the Herndon Alliance decided their problem was not the power of the insurance industry and of conservative politicians who oppose universal coverage, nor was it that Crittenden and his colleagues have a history of promoting unpopular legislation that would have crammed Americans into managed care insurance companies and saved no money. No, the founders of the Herndon Alliance decided the problem is that Americans hold values that are different from those held by universal coverage activists, and someone needs to identify the values of Americans and then draft a health care bill that fits the alleged prejudices of the average American.

You can see what a bootstraps operation this was going to be. The Herndon Alliance didn’t have any research to document their belief that Americans hold values resistant to universal coverage. In fact, research shows just the opposite — that 65 to 85 percent of Americans support universal coverage, and 60 to 70 percent support universal coverage through a single-payer system. Moreover, research and voluminous anecdotal evidence indicate that Americans are hostile to the managed care tactics adopted by the US health insurance industry in the 1980s and endorsed by the Health Security Act, by the bill Crittenden wrote for the state of Washington, and by the legislation that created TennCare. But the Herndon Alliance founders were convinced their prejudices about Americans were true, and they knew they needed “research” to make their preconceived beliefs credible to others. So, some time in early 2006, and possibly late 2005, they hired Celinda Lake to produce that research.

Lake’s research


Lake’s research unfolded in three stages. The first stage purported to examine “core values” held by Americans that related to health care reform, and then to break Americans down into categories based on the “values” they held. As Lake put it in a recent article with Crittenden, “[O]ur research began by exploring voters’ own perceptions and the core values that shape their views on health care.… and segment[ing] the public into clusters of like-minded voters whose core beliefs about health care issues were similar.”24 In the second stage of Lake’s research, focus groups were selected based upon the allegedly health-care-reform-related values identified in the first stage, and these focus groups were asked questions about various health care reform issues and proposals. In the third stage, Lake conducted a poll designed to see how people felt about a health care reform proposal she developed during the second stage (called “guaranteed affordable choice”) compared with single-payer and other proposals. The great majority of Lake’s comments about how “voters” and “people” and “Americans” think are based on the second stage — on the focus group research.25

Lake’s research suffers from three serious defects. First, her “exploration of core values” — the first stage of her research — is so bad it borders on the bizarre. Second, she has never described the methodology she used to conduct the first two stages of her research. To take the biggest problems with her focus groups, Lake has divulged no information on how she selected them nor what questions she put to them. Third, that portion of her research for which Lake has revealed her methods — the third, polling stage — is clearly biased.

Stage One: “Mapping values”

The first phase of Lake’s research for the Herndon Alliance was done in conjunction with a business consulting firm called American Environics (AE) which boasts that its surveys are used by Fortune 500 companies, including L’Oreal and Proctor and Gamble.26 AE published a report for the Herndon Alliance entitled a Road Map for a Health Justice Majority in May 2006. In the report’s introduction, the authors claim the report will answer the question, “Who is more likely to support comprehensive health care coverage for all Americans?”27 But nowhere in the report are readers given the answer to that question.

The AE’s report consists of five chapters and an appendix. The first four chapters contain platitudes about “values,” such as:

[O]ur values are as much a manifestation of the social, political and cultural environments in which we live as they are a reflection of our unique selves; 28 and

[T]here is a decline in traditional religious adherence in most societies, yet religious fundamentalism is on the rise in much of the world.29

Only in the fifth chapter does AE discuss “values” allegedly related to health care reform. It is difficult to exaggerate how chaotic and unintelligible these portions of the report are. If the reader finds the rest of this section difficult to comprehend, that is as it should be. The fifth chapter and the appendix of the AE report are indecipherable. AE claims it has identified 117 “values.” These values, listed in the appendix with one- and two-sentence descriptions of them, have names like “brand apathy,” “discount consumerism,” “upscale consumerism,” “more power for big business,” “meaningful moments,” “mysterious forces,” “traditional gender identity,” and “sexual permissiveness.” “Discount consumerism” is defined, for example, as “preferring to buy discount or private label brands, often from wholesalers.” “Meaningful moments” is described as, “The sense of impermanence that accompanies momentary connections with others does not diminish the value of the moment.”

AE offers no explanation of its methodology (AE asserts the methodology is “proprietary”). It is not clear how AE determined that Americans hold these “values.” (Did AE employees actually ask average Americans, “Do you savor the sense of impermanence that accompanies momentary connections with others”?) It is not clear why the vast majority of the 117 “values” deserve to be called “values,” and it is not at all clear how any of these “values” relate to health care reform. Only two of the 117 “values” had “health” in their titles, and these (“effort toward health” and “holistic health”) had nothing to do with health care reform. The word “medicine” appears in none of the titles and only once in the entire appendix. Other words with direct relevance to the modern health care reform debate — words such as “insurance,” “premiums, “doctor,” “prevention,” and “taxes” — appear nowhere in the appendix. Nowhere in the report does AE make even a feeble attempt to convince the reader that its 117 “values” should be called “core values that shape … views on health care,” as Lake puts it.

Having assembled its list of 117 “values,” AE then asserted it could break Americans into eight categories — AE called them “clusters” — based, it appears, on the extent to which people in these clusters shared some of the 117 “values.” AE did not explain how they did this.30 AE first constructed a cluster they called “The Health Justice Base.” It is not at all clear how this cluster differs from the other seven clusters, but one gathers from the name alone that these folks are the most enthusiastic advocates of “health justice,” whatever that means. AE reports that 100 percent of the members of the Health Justice Base are “for comprehensive health care.” Is “comprehensive health care” synonymous with “universal coverage” or “universal health care”? We are not told. AE determined that only 13 percent of Americans fall into the Health Justice Base. For two reasons, this 13-percent estimate seems outlandishly low. First, polls indicate 65 to 85 percent of Americans believe that health care is a right.31 It is hard to imagine a more fundamental requirement for a “health justice” advocate than someone who is willing to say health care is a right. As Daniel Yankelovich, a well known pollster, put it:

The belief that health care is a right is deeply ingrained in the American consciousness, especially government’s obligation to ensure health care for those who are too poor to pay for it. When any benefit is regarded as a right, Americans automatically assume that it is the government’s responsibility to honor it. The public has held this conviction for more than half a century. A 1938 Gallup poll reported that 81 percent of adults nationwide believed that “government should be responsible for medical care for people who can’t afford it.” Fifty-three years later the number was 80 percent — a remarkably stable conviction.32

Second, AE also claimed that more than 80 percent of every other cluster except one (a cluster called the Anti-Health Justice Base) was “for comprehensive health care” (only zero percent of the Anti-Base expressed support for “comprehensive health care”). The Anti-Base accounts for only 6 percent of the population. If the other 94 percent believes, by majorities in excess of 80 percent, in “comprehensive health care,” why are the huge majorities in these other clusters not counted as part of the “health justice base”? The disorganized data that AE provides for the Health Justice Base (and each of the other clusters) offers no answers. AE gives us a long list of some of the 117 “values” that apparently have something to do with the Health Justice Base (these include “Meaningful Moments” and “Look Good Feel Good”) as well as fragments of other data (like only 24 percent of the Health Justice Base voted for Bush in 2004). Then AE offers some commentary about the Americans who fall into this category that can only be called psychobabble. We learn, for example, that members of the Health Justice Base may be proud of their daughter who holds a full-time job and raises three children “(high on Flexible Gender Identity and Gender Parity) but deep down it makes them feel a little uncomfortable that she makes more money than her husband and they wonder how it may affect his authority within the family (higher than average on Patriarchy).”

(The phrases in italics in the preceding excerpt refer to some of AE’s 117 “values.”)

Now, let’s stop and consider this profound finding. Assuming it is true that all or nearly all of the folks who find themselves in the Health Justice Base worry that their daughters’ marriages may be at risk because they make more money than their husbands, so what? How are we supposed to craft an advertisement or a speech about health care reform, much less an actual health care reform proposal, based on such a strange factoid? AE and Lake don’t say.

At the other end of the continuum from the Health Justice Base AE created the “Anti-Health Justice Base.” Here is some AE commentary about these people: “The young men of the Anti-Base would rather listen to ‘American Idiot’ by Green Day on their iPod than read an article about President Bush’s latest energy proposal.”

In between the Health Justice Base (13 percent of the population) and the Anti-Base (6 percent) are the following six “clusters:”

Proper Patriots (34%)
Marginalized Middle-Agers (17%)
Mobile Materialists (13%)
Drifters (10%)
Autonomous Idealists (4%)
Young Achievers (4%)

AE offered descriptions of these groups that were just as amusing as its descriptions of the Health Justice Base and the Anti-Base. Here, for example, is how AE stereotyped the Mobile Materialists:

This group tries to impress others with their homes, cars, clothes and looks, scoring high on Status via Home, Buying on Impulse, Importance of Brand, Joy of Consumption, Crude Materialism and Ostentatious Consumption. Despite the occasional twinges of guilt they feel about this materialism (Voluntary Simplicity), for the most part the new rims for their car or yet more designer handbags are welcome escapes from everyday drudgery. They tune out after work by watching MTV Cribs (Living Virtually) and feel best when they make time for a workout at the gym or a mani-pedi (Look Good Feel Good, Concern for Appearance).

AE and Lake refer to the six clusters between the Health Justice Base and the Anti-Base as “constituencies of opportunity” and, alternatively, “swing voters.” AE and Lake imply that people in these six clusters “of opportunity” are not for or against “health justice” (the term “health justice” is nowhere defined in the AE report). But, say AE and Lake, the swing voters do share some of the 117 “values” with the Health Justice Base, and if we can just figure out which values those are and then craft language to appeal to people who hold those values, we can induce these six swing clusters to think like the Health Justice Base and, apparently, like the people who founded the Herndon Alliance.

The “values” that the “swing voters” share with the Health Justice Base are called “bridge values.” Thus, we learn that Proper Patriots share with the Health Justice Base the following “bridge values,” among others: “National Pride,” “Selective Use of Professional Services,” “Obedience to Authority,” and “Brand Apathy.” Again, how AE and Lake know this is never explained. Why does it matter that both Proper Patriots and members of the Health Justice Base suffer from “brand apathy”? Only AE and Lake know.

As you can see from the list of the six “constituencies of opportunity,” the largest are the Proper Patriots, Marginalized Middle-Agers, and Mobile Materialists. Together, these people make up nearly two-thirds of the American population, according to Lake’s and AE’s mysterious calculations. Although Lake habitually says her conclusions apply to “Americans,” “people,” and “voters,” that is apparently not accurate. Lake states in some but not all of her public statements that she focused on the Proper Patriots, Marginalized Middle-Agers, and Mobile Materialists in the second and third stages of her research. Obviously, if the values these clusters were based on are shallow or fanciful, and if the breakdown of Americans into “clusters” was done by an unknown and possibly whimsical process, all research based on these “clusters” is suspect. By Lake’s own admission, all of her research is based on the AE report. That report may actually be of some use to a firm like L’Oreal trying to figure out whether to depict a consumer in one of its ads as someone who enjoys “looking good and feeling good.” But as a report upon which to build a health policy or a message about health policy, it may fairly be dismissed as nothing but silly conclusions based on occult methods.

Stage Two: Focus groups

This stage began in the summer of 2006 when Lake’s polling company, Lake Research Partners, assembled eight focus groups, each with eight to ten people. Some of these groups were assembled in Atlanta, Georgia and some were convened in Columbus, Ohio. Ten more focus groups were convened in Denver and San Diego the following summer.33 There are two serious defects in this stage of Lake’s research: (1) She provides almost no information on how she selected the participants for her focus groups, and what information she provides suggests her participants did not represent the American population; (2) She provides no information on what questions were posed to the focus groups and whether and how the facilitators responded to any particular “value” or opinion expressed by participants.

According to Lake, the focus group participants were picked in a way that guaranteed that each focus group had members who reflected the “values” of some of the eight clusters created in stage one. Participants were selected to represent either (a) the three big “swing clusters” or (b) all six of the clusters between the Health Justice Base and the Anti-Base (it is not clear from Lake’s various explanations which description is accurate).34

Lake asked these focus groups questions that she won’t share with the public.35 Thus, we have no idea how the topics about which Lake reports were generated within the focus groups, or how Lake or her staff responded to comments from focus group participants. Consider, for example, this comment by Lake at what was apparently her first public report to the Herndon Alliance:

We had people in our focus groups saying, “Well, this is Canadian-style healthcare,” and we found that the answer was, “No, no. This is American healthcare.” 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.”36

Anyone with a reasonably inquisitive mind would like to know what statement by Lake or her employees the “people” were responding to, and what portion of the focus group participants reacted that way. The word “this” appears three times in the preceding statement by Lake. It is reasonable to infer that “this” referred to something Lake or her staff said or presented to the focus group. But Lake gives us no clue what “this” might have been. When “people” reacted negatively to “Canadian-style health care,” did Lake or her employees respond? If so, what did they say? Lake gives us no clue. Note, finally, Lake’s habit of saying “people” and “voters” said this or that. How many “people”? She doesn’t say. Were they representative of the American population, or even the focus group? She doesn’t say.

Here is another example of a report on the focus groups, this one from Michael Shellenberger, an employee of AE (Shellenberger was the one I quoted earlier about Americans thinking their parents are “undeserving”):

People raised issues of the non-working, the lazy, the illegal immigrants. We also had a lot of stories of people on welfare getting better benefits than they were getting. People didn’t feel like welfare reform had solved that problem.

How did a focus group convened to discuss health care reform wind up talking about “the lazy” and “people on welfare”? Did Lake raise this issue? We have no idea. Note again the habit of saying “people” said this or that. Did the complaints about “the lazy” and “people on welfare” come from a majority of the participants? Were they representative of the American population? Lake doesn’t tell us.

One last example of how Lake portrays her focus groups: In explaining why “people” don’t like Medicare, Lake said, “And people also believe in terms of Medicare that they have to buy supplemental policies.”37 This vague statement has three implications: (1) Lake or her employees told the focus groups that single-payer advocates in America propose a national health insurance program based on, or similar to, Medicare; (2) someone (Lake, one of her employees, or possibly a focus group participant) then reminded the participants that one drawback of the current Medicare program is that most Medicare recipients who can afford to buy supplemental coverage do; and (3) no one pointed out that single-payer legislation proposed in America provides coverage so broad that supplemental insurance would not be necessary. Are any or all of these implications accurate? Lake gives us no clue.

Because Lake tells us there are certain words activists should prefer and others they should avoid, it is reasonable to infer that some of the questions posed to the focus groups asked for reactions to certain phrases. On the basis of the responses Lake allegedly got to the questions she won’t divulge, she developed two slides for her talk show that present two dozen pairings of “words to say and not to say,” including:

  • Don’t say “universal coverage,” say “quality, affordable health care”;
  • Don’t say “Medicare for all,” say “a choice of public and private plans”;
  • Don’t say “government health care [as if anyone other than Newt Gingrich uses that term]; public plan,” say “government enforcement/watchdog”;
  • Don’t say “competition,” say “choice and control.” 38

Table 1: Full 2007 guaranteed affordable choice focus group language of Celinda Lake’s PowerPoint presentation to the Minnesota Legislature, “How to talk to voters about health care,” December 5, 2007, p. 10

- Americans would be guaranteed to have a choice of health plans they can afford, either from a private insurer, or from a public plan offered at a sliding scale cost based on income.

- To maintain quality and allow fair cost comparisons, health insurance companies and the public plan would be required to provide at least a standard, comprehensive package of benefits including preventive care and all needed medical care.

- Employers would be required to offer a choice of the public plan and at least one private plan to all employees, including part-time employees.

- Employers and individuals could choose to keep their current health plans or one that offers more coverage beyond the standard plan, but all plans — private or public — would have to cover at least the standard package of benefits.

- The cost to employers would be 8% of payroll, with discounts for small businesses. Employees would pay 4% of their paycheck through a payroll deduction. This would pay for all of their health care, including their dependents, with no additional premiums and no deductibles.

- No private or public insurer could deny coverage or charge higher premiums to people with pre-existing conditions.

- Illegal immigrants would not be eligible for the plan.

- Costs would be controlled by competition between the plans, and by using a nationwide pool to negotiate lower prices within the public plan.

Obviously, these recommendations about word choice constitute the first stages of policy development. If activists are being urged not to say “Medicare for all,” then obviously activists are also being urged not to support a single-payer system. If activists are being urged to say “a choice of private plans,” then obviously activists are being asked to endorse some version of the current multiple-insurer system.

By an unexplained process, Lake or someone working for her fleshed out the details of a proposal that seems to achieve universal coverage (it is impossible to say because Lake has an aversion to phrases that begin with “universal” and doesn’t use such phrases in describing her proposal) and asked the focus groups for their reaction to it. Lake calls her proposal “guaranteed affordable choice.” Table 1 contains the description of this proposal. You can see that it relies on “competition” between insurance companies, even though, as we have just seen, Lake instructs her audiences to conceal this fact by avoiding the word “competition” in favor of “choice and control.”

With one exception, Lake’s proposal looks a lot like the proposals Herndon Alliance founders supported in the past. The exception appears in the first bullet: A “public plan” would be opened up to Americans, and Americans could buy insurance from that plan, as well as from the existing array of health insurance companies. This idea is a central plank in the Health Care for America proposal published by Jacob Hacker, a version of which was adopted by John Edwards, Hillary Clinton, and Barack Obama early in their presidential campaigns.39

Not surprisingly, Lake’s focus groups approved of Guaranteed Affordable Choice. Here are several bullet points from a slide in Lake’s PowerPoint file entitled “Focus group insights on Guaranteed Affordable Choice:”

  • Generally speaking, voters like the concept of Guaranteed Affordable Choice [GAC].
  • Voters tend to perceive a public plan as inferior and need reassurance that they will have a choice and won’t be dumped into a public plan.40

Note again Lake’s use of the word “voters.” We are to believe that Lake’s comments are about all or a very large majority of Americans, not swing voters and not conservative voters.

Lake’s conclusion that her focus groups liked the GAC plan and did not like Medicare or a national health insurance plan based on Medicare was the most significant part of her report to the Herndon Alliance. That conclusion was the deliverable the Herndon Alliance hired her to produce. She did not disappoint them. Because the first two stages of Lake’s research took place in a black box from which almost no information about her methods has escaped, outside observers can only make inferences about how Lake pulled that off. Given the evidence we do have, including the known biases of the Herndon Alliance’s founders, Lake’s refusal to make her methods public, and a large body of evidence contradicting Lake’s findings, it is reasonable to infer that Lake used biased methods at each stage of her research to get the results she wanted.

Stage Three: A poll

To buttress the conclusion she drew from her focus groups that “voters” like the GAC plan and do not like a single-payer or Medicare-for-all system, Lake conducted a poll of 1,000 “likely voters” during September of 2007. Her poll asked respondents, among other things, to compare GAC to three competing proposals, including singlepayer. Here is the single-payer question:

Now here’s a different choice. Which of the following two approaches to providing health care coverage do you prefer? [ROTATE]

  • 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.


  • 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.41

Given the biased wording of this question, it is not surprising that 64 percent said they preferred the GAC “approach” and only 22 percent said they preferred the singlepayer option.

Before we explore the biases, note first of all that merely expressing a preference is not the same thing as expressing opposition. But you would not know that from the comments made by Lake and Herndon Alliance leaders. They characterize this poll as evidence of widespread public opposition to single-payer, not mere preference for the more attractively worded GAC option. Here is an example from a speech by Roger Hickey, co-director of the Campaign for America’s Future, a member of the Herndon Alliance, to New Jersey Citizen Action, another member of the Herndon Alliance.42

[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. And even the hard core progressive part of the population, which Celinda calls the “health justice” constituency, favors “guaranteed choice” over single-payer [emphasis added].43

Speaking on behalf of the Herndon Alliance, Richard Kirsch offered a similarly inaccurate interpretation of Lake’s research:

And we want to be sure that you have a choice besides private insurance and that’s a public plan that’s accountable to all of us. That will lift and elevate the role of government in a way that’s acceptable as opposed to saying your only choice is a government plan which people will go “no.”44

Kirsch and other leaders of the Herndon Alliance have continued to misrepresent Lake’s poll as representatives of Health Care for America Now (HCAN), a new incarnation of the Herndon Alliance. HCAN (a name no doubt adopted to signify the group’s support for Jacob Hacker’s Health Care for America plan) announced its existence in July 2008. Many of HCAN’s leaders and members are also leaders and members of the Herndon Alliance. Richard Kirsch, for example, is the director of HCAN. HCAN recently announced its support for a proposal published by Sen. Max Baucus (DMT) that resembles Hacker’s proposal.

But the 64-to-22-percent vote that Herndon Alliance members misrepresent was in fact based on a very biased question. If you look back at the question, you will find at least four choices of words or omissions of facts that introduced bias into the question:

(1) The definition of single-payer includes the words “government” and “tax,” which even people outside the polling business understand are not attractive words to many people, while those words do not appear in the GAC definition.

(2) The “tax” in the definition of single-payer is not described as “progressive” or “sliding scale,” but it is described as “sliding scale” in the GAC definition.

(3) The GAC 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 GAC 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 by the populace. If Lake and her colleagues are actually claiming the GAC 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 GAC proposal as taxes.

(4) Perhaps most importantly, Lake’s poll failed to alert respondents to unattractive facts about the GAC proposal. These facts include the fact that Americans will not regain their freedom to choose their own doctor under GAC or any other proposal that leaves the current health insurance industry in place. Another unattractive and unmentioned fact is that GAC cannot save money (certainly not as much as a singlepayer can), which means taxes and/or compulsory payments will have to be higher and/or that coverage will be worse under the GAC proposal.

As the GAC plan is described in “How to talk to voters about health care,” there is no reason to believe it will save money. Herndon Alliance leaders apparently believe that inserting a Medicare-like program into the middle of the current insurance industry will lower costs because the Medicare-like program will enjoy low overhead costs and will quickly achieve large size vis-a-vis the private insurers in all or most US cities and regions. The large size of the public program, we are told, will enable it to demand substantially lower provider fees than the private insurers currently pay. These twin advantages — low overhead and large size — will enable the public program to keep its premiums very low compared with those of private insurers, and private insurers will either have to become as efficient as the public program or go out of business.

The Herndon Alliance’s and Lake’s assumptions about low overhead and large size are dubious, and their assumption that these advantages, even if they are achieved, will bring about more vigorous competition in the insurance industry is wrong. There is nothing in Lake’s GAC plan to justify the rosy assumptions she makes for it. There is, however, plenty of evidence to support the conclusion that if a Medicare-like plan is injected into the current system its overhead costs will be higher than Medicare’s (it will have to advertise, for example) and it will attract a disproportionate share of sick people, not because insurers will reject people with pre-existing conditions (something Lake says her proposal will outlaw) but because private insurers will deny services to their patients and drive them to the public plan. Private plans will no doubt continue their practice of finding reasons not to pay bills sent to them by clinics and hospitals. If the public plan starts out in any of the hundreds of local markets with less than an overwhelmingly large market share, it may fail not only to force the private plans to become more efficient, it might well be destroyed by higher overhead costs, by adverse selection generated by the antisocial behavior of the private plans, and by the higher cost of paying all legitimate claims.

Unlike multiple-payer proposals like the GAC plan, single-payer systems can reduce both administrative costs (which absorb more than 30 percent of health care spending) as well as medical costs (which account for the other 70 percent). Administrative savings alone from single-payer systems are estimated to be 10 to 15 percent of total spending.45 Additional savings from reduced provider charges and drug prices could, at the national level, bring spending down another 10 to 15 percent. Further savings in the form of reduced fraud are also likely.

Lake should have alerted her respondents to two facts: (1) single-payer systems can cut costs substantially while proposals like GAC cannot; (2) the savings from a single-payer system will mean either lower taxes or better coverage or both compared with the GAC proposal. It was inappropriate for Lake to pose her question about the GAC plan and single-payer without alerting her respondents to these facts. 46


The Herndon Alliance asked Lake to do the impossible — to find evidence for their belief that Americans don’t want a single-payer system and do want a multiple-payer system, all the while pretending that they had not already decided that a multiple-payer system has to be the basis of any solution to the American health care crisis. Lake gave the Herndon Alliance the conclusions they were seeking, but without any evidence to back them up. All three stages of her research are junk science. Stage one — the AE report — is silly and its methods are concealed. By Lake’s own admission, the AE report is the basis for all her other research. Lake refuses to reveal her methodology for stage two of her research — her focus groups. And the one part of her research for which methods are known — her 2007 poll — was obviously biased.

Lake’s findings conflict with a large body of research (the methods for which are known) on how Americans feel about health care reform. This research indicates Americans are very supportive of a single-payer system. This is evident not just from the ABC News and AP-Yahoo polls I cited earlier, but from hundreds of other polls and several focus group studies. It is evident as well from the widespread support for HR 676, a single-payer bill introduced in the US House of Representatives in 2003. This bill has the support not only of 94 members of the House of Representatives, but of Physiciansfor a National Health Program (which represents 15,000 doctors across the country) and numerous other groups devoted solely to enacting a single-payer system, almost twothirds of the nation’s physicians,47 481 union organizations in 49 states, and 20 international/national unions, including USW, UAW, NEA, ILWU, NALC, IAM&AW, UA (Plumbers & Pipefitters), AFM (Musicians), UE, CNA/NNOC, SMWIA, IFPTE, OPEIU, UTU, SEIU, AFT, AFSCME, CSEA (California School Employees Association), UWUA, and CWA.48

Until Lake reveals her methods and offers a reasonable explanation for why her results are so different from those of other researchers, the public should treat Lake’s research as junk science.

1 Sen. John McCain, “Access to quality, affordable health care for every American,” New England Journal of Medicine, October 9, 2008,, accessed November 24, 2008.

2 2004 Republican platform, unnumbered pages,, accessed August 30, 2008

3 Thomas J. Donohue, President and CEO, US Chamber of Commerce, “America at the crossroads,” address to The State of American Business Conference, National Chamber Foundation, Washington, DC, January 8, 2008,, accessed November 24, 2008.

4 According to the Coalition for Affordable Health Insurance Web site, “CAHI’s membership includes insurance companies, small businesses, providers, nonprofit associations, actuaries, insurance brokers and individuals. Since 1992, CAHI has been an active advocate for market-oriented solutions to the problems in America’s health care system” (, accessed October 17, 2008).

5 In his 2003 State of the Union address, Bush said, “Our second goal is high quality, affordable health care for all” (, accessed November 24, 2008).

6 “Norm [Coleman] believes everyone deserves access to quality, affordable health care.…” (, accessed August 30, 2008).

7 As the Web site of Lake’s firm, Lake Research Partners, puts it, “We are proud to do work for a number of outstanding clients, including: the Democratic National Committee, the Democratic Governor’s Association, AFL-CIO, SEIU, CWA, IAFF, Sierra Club, Planned Parenthood, Human Rights Campaign, Emily’s List and the Kaiser Foundation” (, accessed
November 24, 2008).

8 Here are Lake’s actual words: “Now the irony is, of course, 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” (transcript of Presentation of Herndon Alliance Data by American Environics and Lake Associates, Herndon Alliance, Public Welfare Foundation and Nathan Cummings Foundation , September 29, 2006,, accessed November 24, 2008).

9 “How to talk to voters about health care: Progressive framing and messages,” Presentation by Celinda Lake, December 5, 2007, p. 53.

10 In the face of a large body of anecdotal and empirical research that indicates Americans dislike the health insurance industry and are becoming increasingly angry with the industry as premiums and outof-pocket costs soar and coverage shrinks, Lake repeats over and over that her research indicates “people” like their health insurance. In fact, they like it so much they will resist any health insurance reform that does not allow them to buy health insurance from Blue Cross Blue Shield or one of the other American health insurance companies. Here is a typical example of how Lake expresses this finding

[W]e found that this pre-existing condition issue huge with the public.… And, in fact, … we found that this is the top testing thing that you can offer insured America, voting America. People come to this in terms of how it’s going to affect them personally. And particularly women do this. And women … also the most vigilant about checking the fine print here. They do not want to lose what they have. Now people think they have pretty high quality, right (Transcript of American values, American solutions: Overcoming the barriers to health reform, Herndon Alliance, November 2, 2007, p. 11, http://www.kaisernetwork. org/health_cast/uploaded_files/110207_herndon_script.pdf, accessed November 28, 2008).

11 Here is an example of a statement by Lake that Americans get angry with speakers who compare the US system to the systems of other countries:

And you’ll remember from the first round of research people deeply resentful about being told that America did not have the best health care in the world and, in fact, just absolutely pushed back on that. They were just absolutely going to reject anybody who would say that. And that was rooted in some core values that had nothing to do with healthcare (Transcript of American values, American solutions: Overcoming the barriers to health reform, Herndon Alliance, November 2, 2007, p. 11, http://www.kaisernetwork. org/health_cast/uploaded_files/110207_herndon_script.pdf, accessed November 28, 2008). Note the statement that this resentment “had nothing to do with health care.”

One might well ask what any of the “values” listed in the AE report “had to do with health care.”

12 Lake’s slide show contains a slide that says, “Voters … don’t want to pay for those they perceive to be ‘undeserving’” (“How to talk to voters about health care: Progressive framing and messages,” Presentation by Celinda Lake, December 5, 2007, p. 5, An identical or very similar version of this PowerPoint file is available at, accessed November 29, 2008.

13 Transcript of Presentation of Herndon Alliance Data by American Environics and Lake Associates, Herndon Alliance, Public Welfare Foundation and Nathan Cummings Foundation , September 29, 2006, p. 5, accessed November 24, 2008. This statement was made by Michael Shellenberger.

14 Jacob Hacker, “Putting politics first,” Health Affairs 2008;718-723, 718.

15 Associated Press-Yahoo Poll,, p. 15.

16 Transcript of Health Action 2007 Conference — Day 3: Morning Plenary Families USA, January 27, 2007, pp. 15-16, familiesusa_plenary_transcript.pdf.

17 According to Tom Hamburger, Ted Marmor, and Jon Meacham, Ron Pollack debated singlepayer advocate Ted Marmor at a two-hour meeting in front of Bill Clinton in Washington, DC in 1991. Pollack promoted a system in which employers would be required to make payments to insurance companies. Marmor promoted a single-payer system. When the debate was over, Clinton pointed at Marmor and said, “Ted, you win the argument.” Then Clinton pointed at Pollack and said, “But we’re going to do what he says” (Hamburger et al., “What the death of health care reform teaches us about the press,” Washington Monthly, November 1994, 35-41).

18 Haynes Johnson and David S. Broder, The System: The American Way of Politics at the Breaking Point, Little Brown, Boston, 1996.

19Transcript of American Values, American Solutions: Overcoming the Barriers to Health Reform Herndon Alliance November 2, 2007, p. 54, _script.pdf, accessed November 29, 2008.

20 Robert A. Cittenden, “Managed competition and premium caps in Washington State,” Health Affairs 1993;12(2):82-88, 82.

21 G. Gordon Bonnyman, Jr., “Stealth reform: Market-based Medicaid in Tennessee,” Health Affairs 1996;15(2):306-314, 307.

22 Transcript of Health Action 2007 Conference —Day 3: Morning Plenary, Families USA, January 27, 2007, p. 12,, accessed November 25, 2008.

23 Transcript of Presentation of Herndon Alliance Data by American Environics and Lake Associates, Herndon Alliance, Public Welfare Foundation and Nathan Cummings Foundation, September 29, 2006, pp. 6-7,, accessed November 25, 2008.

24 Celinda C. Lake et al., “Health care in the 2008 election: Engaging the voters,” Health Affairs 2008;27:693-698, 693.

25 I do not discuss here what might be called a fourth stage in Lake’s research described in Lake’s latest slide shows and by Drew Westen, Lake, and several of Lake’s colleagues in a 2008 memo (Drew Westen et al., “How to talk about health care reform: Summary of research for Families USA, the Herndon Alliance, and the AARP,” June 9, 2008, Findings/Report_HealthCare Messaging_ rf_060908.pdf). In this memo Westen and Lake present short statements (they run about one paragraph in length) that Westen and Lake recommend candidates use to argue for “health care reform” and to rebut conservative attacks on “health care reform.” (Westen et al. do not define “health care reform” in this memo, but they nevertheless use that phrase studiously because they have sworn off “universal health insurance,” apparently because they think Lake’s focus group research demonstrated “voters” don’t like that phrase or any other that begins with “universal.”) I ignore this memo here because it introduces no new evidence that would buttress the first three stages of Lake’s research.

26 California Fiscal Policy Project, Road Map for a Tax and Fiscal Majority: A Values-Based Approach, p. 35, May 2007,, accessed July 3, 2008.

27 American Environics, Road Map for a Health Justice Majority: Presented to the Herndon Alliance by American Environics, May 2006, p. 3, Justice_Majority_AE.pdf.

28 Ibid., p. 4.

29 Ibid., p. 9.

30 In response to a letter I wrote to the editor of Health Affairs criticizing Lake and AE for refusing to divulge their methods, Lake et al. offered a vague clue to their methods. They said a “small subset of [the 117 values] predict most of the variance in the public support for universal health care” (“Values research: The authors respond,” Health Affairs 2008;27;1747-1748, 1747). This is an odd confession. As we have seen, Lake recommends that no one ever say “universal health care” or “universal coverage,” and AE obeyed this edict. The phrase “universal health care” appears nowhere in the AE report. And yet, when pressed, Lake et al. claim they actually did attempt to see which of a small subset of the non-health-carerelated values correlated with support for the politically incorrect “universal health care.” To add to the confusion generated by the AE report, AE and Lake did not explain why AE reported 117 “values” if only a few were related to support for “universal health care,” nor why so many “values” were needed to create the eight “clusters.”

31 Support for universal health insurance or a government guarantee of health care tends to be at the low end of the 65-80-percent range when taxes are mentioned. For example, 65 percent said they favor “the US guaranteeing health insurance for all citizens, even if it means raising taxes” (Pew Research Center for the People and the Press, “Beyond Red and Blue: The 2005 Political Typology,” http://typology.peoplepress. org/data/index.php?QuestionID=26, accessed November 29, 2008).

32 Daniel Yankelovich, “The debate that wasn’t: The public and the Clinton plan,” Health Affairs 1995, 14(1):7-23, 12.

33 Celinda C. Lake et al., “Health care in the 2008 election: Engaging the voters,” Health Affairs 2008;27:693-698, footnotes 2 and 3, p. 698,

34 Here is an example of Lake’s vague description of the methods she used in assembling her focus groups: “Eight focus groups were designed and moderated by Lake Research Partners in Atlanta, Georgia, and Columbus, Ohio, in July and August 2006, on behalf of the Herndon Alliance. Each session lasted two and a half hours and included eight to ten voters who were screened to fit a given health care values segment” (Celinda C. Lake et al., “Health care in the 2008 election: Engaging the voters,” Health Affairs 2008;693-698, endnote 2, p. 698).

35 I requested Lake’s methodology several times by email (sent to Lake Research Partners) in early 2008, and was turned down.

36 Transcript of Presentation of Herndon Alliance Data by American Environics and Lake Associates, Herndon Alliance, Public Welfare Foundation and Nathan Cummings Foundation, September 29, 2006, p. 44,, accessed November 29, 2008

37 Transcript of American Values, American Solutions: Overcoming the Barriers to Health Reform, Herndon Alliance November 2, 2007, p. 13,, accessed November 29, 2008.

38 Herndon Alliance,, accessed November 25, 2008.

39 Jacob Hacker, “Health Care for America,” January 11, 2007,, accessed November 29, 2008.

40 Herndon Alliance, “How to talk to voters,” December 5, 2007,

41 Poll for the Herndon Alliance, September 15-27, 2007, question 27, personal communication, Bob Crittenden, January 31, 2008.

42 Herndon Alliance, “Herndon Alliance Partners,” partners.php, accessed November 29, 2008.

43 Roger Hickey, “Real health care solutions,” Common Sense, November 15, 2007,, accessed November 16, 2007.

44 Transcript of American Values, American Solutions: Overcoming the Barriers to Health Reform, November 2, 2007,, accessed November 29, 2008.

45 US General Accounting Office, Canadian Health Insurance: Lessons for the United States, Washington, DC, 1991; and Steffie Woolhandler et al., “Costs of health care administration in the United States and Canada,” New England Journal of Medicine 2003, 349:768-775.

46 Arguably, a fifth bias was introduced by Lake’s description of the coverage each option would offer. She said the single-payer proposal would cover “a comprehensive set of medical services” while the GAC proposal will “cover all necessary medical services.” The latter phrasing is somewhat more emphatic and precise and, coupled with the word “guaranteed” earlier in the GAC description, creates the impression that the GAC promise is more dependable.

47 Danny McCormick et al., “Single-payer national health insurance: Physicians’ views,” Archives of Internal Medicine 2004;164:300-304; and Joel Albers et al, “Single-payer, health savings accounts, or managed care? Minnesota physicians’ perspectives,” Minnesota Medicine, February 2007:36-40.

48 Kay Tillow, personal communication, November 28, 2008.