by Ivan J. Miller, Ph.D, Executive Director, Colorado Foundation for Universal Health Care
Those of us involved in the Improved Medicare for All (IM4A) movement have seen support grow across the country. But for the movement to succeed, support must grow even more powerful. A 2020 Gallup survey reports 50% of Americans support and 43% oppose a one-payer national health plan. This narrow margin is not enough to make substantial change in our health care system. Challenged by some of our team at the Colorado Foundation for Universal Health Care (Foundation), I have been on a quest to find messaging that resonates with people.
The Foundation’s messaging team finds it useful to assume that 30% of the people are solidly on the support side and 30% are solidly on the oppose side, and that these groups on each end of the continuum will not change position. This leaves 40% of Americans who have not decided whether or not to support an Improved Medicare for All health care system. They are those in the middle who can be persuaded to one side or the other. We’ll call them the persuadables. Our education and messaging mission is to find out who these 40% are and what would move them to enthusiastically support IM4A now.
The conventional way to develop messaging is to hire a marketing expert to conduct surveys and focus groups. The consultant would then develop messages based on findings. Because we do not have the funds for this kind of marketing, we need another way.
In 1994, while developing a small marketing company for 75 independent psychotherapists, I was inspired by Jay Conrad Levinson’s 1984 book, Guerrilla Marketing. He showed that with creativity and strategic thinking, small businesses can compete by finding ways to obtain messaging information from material that is publicly available. My search for accessible polling and focus group information led to an organization that opposes our message — the Partnership for America’s Health Care Future (PAHCF), an alliance of the pharmaceutical and insurance industries, for-profit hospitals, and others who prosper in the current health care marketplace. Their mission is to maintain the multi-payer health care system and defeat single-payer proposals. As our opponents, they want to find out who the persuadables are, and, like us, persuade them to their point of view. Funded by these wealthy industries, their messaging is undoubtedly based upon the work of expensive consultants, extensive polling, and in-depth focus groups. The messaging resulting from their findings is displayed on the PAHCF’s “about us” webpage. Paradoxically, this website is a gold mine of information about how to convince the persuadables to support IM4A.
Who are the persuadables?
PAHCF defines the current system as an “employer-sponsored insurance system.” It is likely that their consultant found messaging about “employer-sponsored insurance” more successful than referring to it as “the health care insurance industry.” The website claims that employer-sponsored insurance covers 180 million people, which is likely the group their consultant determined could won over to their side.
This group has insurance. Their health care costs are reduced because employers pay a substantial portion. They likely think that they have a pretty good deal, which they do compared to their cohorts who do not have employer-sponsored insurance. With universal health care, they would lose both the employer’s contribution and their current insurance. The PAHCF messaging suggests this group could be persuaded that if IM4A replaced their insurance, they might lose some quality, choice or control over their treatment.
They may also believe that because they have good insurance, any new taxes for expanding health care would fund other people’s health care. Indeed, this is the case with incremental expansions of health care coverage, including the ACA. This perception that they have nothing to gain can make them more reluctant to support IM4A.
The PAHCF messaging does not mention the people who buy insurance on the individual market, suggesting they found those people are less likely to support the current system and more likely to be persuaded to support IM4A.
Overview of PAHCF messaging
The first paragraph of the PAHCF mission statement is organized around the phrase “Build on what’s working in health care and fix what’s not.” PAHCF decided to make this phrase their overall theme. Their consultant and research must have found this commonsense statement to be a winner.
The PAHCF messaging professes that it can solve health care problems by building on employer-sponsored health insurance, which they claim is a system that is working. The main thrust of their messaging is that the employer-sponsored insurance system has the best quality, offers most choice, and gives patients the most control over their health care, and this successful, quality health care should not be replaced by a one-size-fits-all program.
They consider Medicare for seniors and Medicaid for those in need to be important components of the current system. Both programs are praised and supported. They frame universal health care as threat to these great programs.
The PAHCF has adopted our two strongest arguments — that everyone should have health care and the system is broken. They even promote these two arguments as their own. The difference is that they talk about everyone having health care insurance instead of health care. They imply it should be incremental and argue for expansion of coverage through the current system.
The PAHCF is winning the messaging battle for popular support. While support for IM4A grows slowly, Kaiser Family Foundation found that 58% of the support disappeared when respondents were told that, with IM4A, insurance companies would be eliminated. Gallup Polls report that among Democrats and Democratic-leaning voters, 55% prefer the incremental step of expanding the ACA while 40% prefer Medicare for All.
Politically, PAHCF’s message has been extremely successful. Moderate Democrats, corporate Democrats, and almost all health care advocacy nonprofits profess that they solidly endorse health care for everyone and that health care is a human right, but they profess that they are working toward it through incrementalism.
Greg Smith, a retired CFO for multiple large corporations and the Foundation’s Business Outreach Coordinator, posed a marketing question for us. “Since you have by far the best product (plan to fix the health care system), why are you having trouble selling it to the American people. There must be something lacking in your marketing. What is it?”
The movement’s advocacy work has been based on two big arguments – that everyone should have health care and that there are terrible problems with our current system. It has been assumed that winning those arguments, the logical conclusion would be IM4A. As the PAHCF has shown us, the persuadables do not necessarily conclude that IM4A is the solution and can be misled to think that the multi-payer system can be the cure.
From a marketing perspective, we have made two fundamental mistakes. First, we don’t have a concise description of what IM4A is. How can we expect to sell a product without saying what it is?
Second, we have not said enough about what a great product it is. You cannot expect to sell a product by spending most of your energy talking about how horrible the competition is. Marketing and selling IM4A requires educating people about what a great, comprehensive, trustworthy, and quality health care system IM4A is.
With the guidance of the PAHCF research, we can improve our marketing in major ways.
Build on what is working
Thank you, PAHCF, for coming up with the message, “Build on what’s working in health care and fix what’s not.” Our side needs to get on this winning message, because we are its rightful owners. We have evidence of what’s working in the U.S. via what we’ll call the Great American Health Care Experiment. This real-life experiment compares Medicare with the multi-payer health care system, and clearly shows that Medicare is the system that works. Medicare and Medicaid were created in 1965, and Medicare, a single payer system, was given the responsibility for the health care of people over 65. (The multi-payer health care marketplace, including Medicaid as a partial safety net, was given responsibility for people under 65.) The Medicare system was at a disadvantage because it needed to care for older and sicker patients with complex needs. In spite of this disadvantage, Medicare still showed that it is the superior system. A proven, effective, efficient and popular program, Medicare has out-performed health care insurance in customer satisfaction and cost. Medicare is the system that works best, and the improvements in IM4A fix the parts that are not working well.
America’s lack of awareness of the Great American Health Care Experiment is shocking. Defenders of the status quo constantly argue that Medicare for All would be a newly created system unlike anything we have known. They have framed the most successful health care program in the country as an untried experiment.
The IM4A movement needs to get the truth out and speak out about Medicare winning the Great Experiment every place possible. We need to raise awareness to the point that it is common knowledge that Medicare outpreforms employer-sponsored health care insurance.
Focus on the fix
The second part of PAHCF’s message, “Build on what’s working, and fix what’s broken,” concedes that there is a lot wrong with the health care system. Each new horrific failure, even a pandemic-sized failure, is framed as just something to be fixed.
The ACA is a good example of attempting to fix what’s broken while keeping the multi-payer system in place. The ACA eliminated pre-existing condition exclusions and made health care available to some who hadn’t had coverage before. Most importantly, the ACA expanded Medicaid. However, to achieve these gains, overall health care costs went up and the system was made even more complex. These drawbacks made the ACA unpopular. Only when some politicians tried to take it away did those benefitting from the ACA speak up. Like so many parts of the health care system, the ACA helps some people and for many is better than nothing.
Medicare is not perfect. IM4A is different than Medicare. The “Improved” part in the name moves it from a program that out-preforms employer-sponsored insurance (a low bar), to a truly superior health care system. We know where the problems are and what needs to be done to fix them. And with all these improvements, IM4A still saves money.
In order to sell the IM4A solution to the public, we need to tell people what IM4A is. Referring to complex legislation, such as HR 1384 or S1129, is no substitute for a straightforward description. Partial descriptions such as saying it adds dental, vision and hearing services do not encapsulate other important issues of quality, cost, and provider payments. We need a concise description of the added benefits and enhancements in IM4A.
Here is the Colorado Foundation for Universal Health Care’s current list of the ways IM4A improves on Medicare. It is an aspirational list, and each of the many independent organizations or leaders in the IM4A movement may alter it and have a slightly different list. These variations aren’t the point. There is mostly common ground that holds the movement together, and each organization or leader may describe the aspirational dreams in a slightly different way. When legislation is developed it can be measured against the shared goals of our movement.
The word “improved” alone, is not enough to pique interest. It is one of the most overused words in marketing and politics. Most of the time the improvements are not as great as they are touted to be, and often, the idea of improvement is a lie. As all of us know, members of an audience will energetically talk about what is wrong with Medicare in spite of the word improved.
The description of the benefit additions or enhancements are the key, and they should be introduced early in a marketing pitch. Solely talking about health care equity or justice at the beginning of a presentation may result in a large part of the audience tuning out thinking that it is the same old pitch.
The description of key “Improved” enhancements and benefits set IM4A above the proven Medicare system and infrastructure. With the fixes, IM4A is the real deal.
Improved Medicare for All would:
- Include dental, vision, hearing, affordable drugs, durable medical equipment, long-term care, improved mental health services, all of the more comprehensive services that are part of Colorado Medicaid, and the popular Silver Sneakers program.
- Eliminate the expensive middleman insurance companies that control Medicare Part D and Medicare Advantage.
- Regulate the cost of drugs, devices, transport, and other services essential for life and health.
- Make Medicare affordable by providing full benefits without deductibles, coinsurance, or copays, thus eliminating the need for supplemental or gap insurance.
- Allow full choice of health care provider.
- Cover the full range of reproductive health care including pregnancy, birth, contraceptives, and abortion services.
- Negotiate with health care providers from each specialty for fair and equitable compensation that recognizes their experience, skills, and training.
- Include public health services that prepare for pandemics; improve vulnerable, rural, and underserved community access; and focus on infectious disease and prevention.
Explanation of Benefit Improvements & Inclusion of Medicaid Benefits
This expansion of benefits is necessary so that IM4A covers the full range of health care needs.
In Medicare Advantage and Medicare Part D, insurance companies serve as middlemen between Medicare funds and the patient/provider team. They have tripled the amount of administration costs, increased overall costs, and are turning Medicare into a typical insurance package that promises a lot but in practice has obscure limitations and restrictions and excessive preauthorization requirements that are not part of traditional Medicare.
Regulate pharmaceuticals as an essential public good
Pharmaceuticals are a matter of life and death. If a product is essential, there is no limit to the amount a supplier may charge. IM4A would regulate the cost of pharmaceuticals in the same manner as essential public utilities. This type of regulation would allow for incentives for new medications, research, and a reasonable profit, but not allow profiteering or charging more than people in other countries pay for the same medication.
Eliminate harmful financial barriers including deductibles, co-insurance, and copays
Medicare has co-pays, co-insurance, and deductibles that keep many seniors and others from being able to afford it.
Full choice of health care provider
Medicare’s history and reputation for full choice of provider has been sullied by Medicare Advantage plans that use narrow provider networks to cut costs. IM4A would restore full choice of provider.
Full reproductive services
A universal health care plan must ensure that every patient has the religious and personal freedom to choose the health care services they want and need, including reproductive services.
Fair provider compensation
IM4A needs a trustworthy mechanism for ensuring adequate provider compensation. In general, provider pay is not the cause of the out-of-control health care costs, and some specialties such as primary care and psychiatry are currently under-compensated. IM4A needs a trustworthy method and a Board that includes provider representatives for ensuring adequate provider compensation while controlling the payments to some specialists who are overcharging.
Public health services
As the pandemic has shown us, we are all in this together. A universal health care system needs a public health mindset. Preparation for pandemics and epidemics is crucial. Vulnerable, underserved, and rural communities may need extra consideration. Infectious disease is a concern for the general public as well as the individual. And prevention, of course, is a priority for maintaining public health.
Medicare is not perfect, but we know what improvements are needed to fix it. With this list, IM4A fixes what is not currently working. There are no proposals that come close to fixing the myriad of problems in the current multi-payer system. After decades trying to fix it, our country has created the most complex and expensive health care system in the world, while still leaving millions uninsured and under-insured.
The PAHCF webpage emphasizes three reasons consumers could be persuaded to want to keep the employer-sponsored health care insurance system — quality, choice, and control.
The idea of quality may be the most powerful reason people do not want to give up their insurance. It is well known in health care economics that when it comes to health care, particularly for serious conditions, people do not have cost consciousness and will pay enormous amounts to get the best.
When it comes to quality, IM4A has some handicaps from the get-go.
- In the market system, people are used to paying more for quality, and it is presumed that because employer-sponsored health care costs so much, the higher cost must pay for premium quality health care.
- Many people have an unexpressed belief idea that if a system combines people with great health care with people who have poor or no health care, everyone will have medium or mediocre health care. Indeed, many of the persuadables want to know if a single-payer system would give them the option of paying more for higher-quality care.
- Employer-sponsored insurance is associated with the highest quality because, in the health care insurance marketplace, the best insurance plans come from employer-sponsored insurance.
- Privately financed services sometimes offer higher quality than the equivalent government-financed services.
PAHCF messaging associates employer-sponsored health care with the highest quality health care. Examples of the quality messaging on their mission web page include:
“Tens of millions of patients and families to receive world-class care delivered by world-class doctors and hospitals;”
“working together to ensure every American has access to the affordable, high-quality coverage they deserve;” and
“access to the world’s best doctors, nurses, specialists, treatments, and technology.”
These messages about quality are repeated over and over in insurance brochures.
Contrast these statements about quality with the messages that come from the IM4A movement. We promise health care like foreign countries have and promote that everyone will have the same health care. These IM4A messages about quality do not have the same attraction as our opponents’ messages about the best doctors and hospitals in the world.
T.R. Reid’s Sick Around the World, other reports or analyses, and many travelers’ personal experiences all attest to the quality of health care in other countries and have converted many to the single payer movement. However, this argument seems unlikely to convince most people. Meanwhile, we have a shining example of excellent health care in the U.S. Medicare system, and discussions of foreign health care can distract from this example.
The insurance industry has been successful in selling the idea of quality. People spontaneously tell many positive health care stories about how medical care or a physician saved their life. These stories often include the statement, “Thankfully, I had great health care insurance and was able to get great care.” Providers screen patients by asking what health care they have before they accept them as a patient, which in a market system leaves the impression that it takes special insurance to get the good health care. Indeed, when I had a so-called good commercial health insurance card, I was proud to show it to a provider and to be among the ones privileged to get good health care.
I have the same feeling now with my Medicare card. Patients with Medicare have access to all and usually more doctors, hospitals, and technology than employer-sponsored health care offers. The U.S. has some world class health care, and most providers accept Medicare. It pays for out-of-state specialty clinics like the Mayo Clinic, while commercial insurance likely would not authorize treatment there. In addition, it would increase the incentive for innovation because advances would be available to all not just the group that is currently well-insured.
Bragging and promoting do not come easily to progressives. As people who value equality and seek to eliminate unjust inequities, it is not natural for us to say that our system, IM4A, is the best. However, it is the best.
Choice is the second of PAHCF’s big three messages that we should own as ours. They use a deceptive, short message: “Don’t choose a one-size-fits-all system.” The reality is that the insurance industry offers products that restrict benefits and offer narrow networks that limit access to providers. With Orwellian doublespeak, they make this choice of restrictions look like it is a greater choice than no restrictions. That’s backwards to the way choice should be.
IM4A offers full choice of provider and the broadest benefit package, which includes mental health, dental, vision, hearing, and long-term care. It has no deductibles or other barriers to care, offers full choice of provider, and the full range of medically necessary treatments. That’s real choice.
IM4A proponents need to brag about the real choice IM4A offers. Bragging is necessary because we cannot expect people to choose IM4A unless they know how good it is. We need to also call out the insurance industry doublespeak about “choices” that result only in limiting your choices.
Control, the third of the PAHCF’s big three, is another message that IM4A should own. Health care insurance cost-cutting increasingly relies on pre-authorizations, which interfere with the patient’s and providers’ control over treatment. Adding insult to injury, the cost of pre-authorization harassment is not classified as an administrative expense, but it is classified as a patient benefit. The guidelines for pre-authorizations are often secret, and consequently undermine patients and providers by not letting them know the rules for obtaining medically necessary treatment.
Traditional Medicare has proven to be much less intrusive than health care insurance. It uses a successful retrospective review process that allows the patient/provider team to make their own treatment decisions. When the guidelines for medically necessary treatment have limits, the rules and regulations are publicly available. IM4A would greatly enhance the ability of patients and providers to control treatment.
A methodical inquiry conducted by the Foundation is relevant. Early this year, the Foundation met with a marketing consultant for large corporations who is also a supporter of IM4A. We created a list of all of the criticisms and concerns that we heard during the campaign to pass a 2016 ballot initiative for universal health care in Colorado. With the consultant’s guidance we looked at the values that underlay these voter concerns. What we found is that voters were primarily concerned with two key values or concepts: Trust/Control. Trust is about health care you can trust and count on. It includes quality. Control is about choice and people being able to take charge over their own care (rather than health insurance companies controlling it). These key concepts underline the PAHCF findings while adding the concept of trust.
IM4A is the trustworthy solution. It improves upon Medicare, which has been proven for 55 years covering everyone over 65 well and out-preforming health care insurance plans in cost and satisfaction.
We in the movement need to spread the messages about what a superior plan IM4A is. We need to spread the word about the Great American Health Care Experiment. Medicare has passed the test of time.
Horror stories can motivate people, but stories and testimonials about Medicare’s great health care will make people want to choose it.
IM4A is the proposal that builds on what’s working and fixes what’s not. It offers quality as high as expensive insurance plans. It has more choice, more patient/provider control, and is more trustworthy than commercial insurance.
The PAHCF’s campaign messaging is misleading and at times doublespeak. IM4A is the truthful owner of the messages promoted by the PAHCF.
The key improvements in IM4A fix the imperfections in Medicare. We need to talk about these key improvements so that the American people know what IM4A is.
With decades of attempting to fix it, the multi-payer system has only become more complicated, more expensive, and more problematic.
IM4A is amazing. With IM4A, not only does everyone get health care, but it is provided through the Medicare system, a system that has proven reliable, trustworthy, and less expensive for 55 years and outperforms health care insurance. As with Medicare, everyone would have access to the world-class health care available in the U.S. We thank PAHCF for showing us the results of their research about the persuadables. With the benefits and enhancements that are added to Medicare in IM4A, IM4A has the broadest benefit package of any health care program. As the truthful owners these messages, let us start using them. Let’s start bragging more about how good IM4A is.
Medicare works. IM4A is a superior health care plan. It’s the real deal. Let’s give IM4A to everyone.
 Kaiser Family Foundation (May 27, 2020) Public Opinion on Single-Payer, National Health Plans, and Expanding Access to Medicare Coverage. https://www.kff.org/slideshow/public-opinion-on-single-payer-national-health-plans-and-expanding-access-to-medicare-coverage/. Slide 1
 Levinson, J. C. (1984) Guerrilla Marketing: Easy and Inexpensive Strategies for Making Big Profits from Your Small Business. Boston: Mariner Books.
 Op cit, Partnership for America’s Health Care Future
 Op cit, Kaiser Family Foundation, Slide 9
 Masterson, L. (2019) Original Medicare tops ratings in survey, beating out Medicare Advantage and employer plans. Insurance.com. https://www.insurance.com/health-insurance/health-insurance-plan-ratings
 Link to list of key benefit improvements on Foundation website: https://couniversalhealth.org/2020/08/04/whatsimprovedinim4a/
 There is no official list of the improvements in IM4A because the concept of IM4A is promoted by a number of independent groups, thought leaders, and elected officials. The list is the Foundation’s current version of the improvements that are commonly endorsed by IM4A. Other IM4A groups, leaders, or elected officials may choose to make their own definition by modifying this list or creating one of their own.
 The Colorado Medicaid program is used here rather than a generic Medicaid program because it is one of the most comprehensive in the country.
 Reid, T.R. (2009) The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. Penguin Group, New York, NY.
 While discussions of foreign health care seem to have little impact on the persuadables, the message that the U.S. is the only industrialized country that does not have universal health care has had some success. It shames those who believe in American exceptionalism and also makes universal health care a normal governmental goal, not just a socialist goal.
 Traditional Medicare programs are different from Medicare Advantage programs. Medicare Advantage plans are run by insurance companies that are given extra funding and allowed to change some of the Medicare rules. The Advantage programs offer highly visible benefits that are greater than traditional Medicare, and they also have many hidden ways of decreasing benefits such as the extensive use of pre-authorization.