To Know the Disease

For the third time in thirty years, we are in the midst of a debate over the American health care system, this time against the backdrop of the Democratic Party’s presidential nomination race. Elizabeth Warren and Bernie Sanders stand alone among the candidates in pledging to introduce Medicare for All while abolishing private health insurance, whereas other leading candidates, notably Joe Biden and Pete Buttigieg, vehemently attack that plan.

Given the well-attested fact that we pay more than any other developed nation for a system that offers poor care and bankruptcy for millions of Americans, it may seem surprising that arguments against reform find fertile ground, including among ambitious politicians. So it must be understood that the attacks on reform are part of a carefully crafted campaign deployed by an immensely wealthy corporate coalition determined to preserve its profit flow. Key to this campaign are the public relations professionals, skilled at manipulating opinion on behalf of their clients in ways few outsiders perceive or understand. Wendell Potter was one of them. Rising to head of corporate communications for the $70 billion health insurance giant Cigna, he was a field commander in the battle to protect industry profits, including the crushing of Hillary Clinton’s reform initiative. But there came a day when, as he wrote in his best-selling memoir, Deadly Spin, “it finally dawned on me that, in my own quest for money and prestige, I had sold my soul,” leading him to walk away from his powerful and lucrative position. As a rare high-level defector, he provides illuminating, vital insights into the ways of his former employers and their amen chorus in the current political arena.                       

Do you find the themes in the current debate over Medicare for All familiar from previous battles over health care reform?

I absolutely find them familiar. I see the hand of my old employer, my old industry, trying to shape the way people think about health care reform, and to shape the debate. They’re using largely the same themes, the same talking points, and the same general strategy. They have new tools, or at least new ways of communicating. One thing that’s a bit different this time is how they’re using social media, which in years past wasn’t available. They’re using Facebook and other platforms to try to persuade people that Medicare for All is not good policy. That’s really the only difference here.

When I say “they,” I’m talking about the insurance industry, but also other major players in health care, big pharmaceutical companies and hospitals in particular. They often publicly point the finger of blame at one another for rising health care costs, the rising number of the uninsured, and so on, but behind the scenes they work collaboratively to protect what is, for them, a very profitable status quo.

What does their general strategy look like?

They’re following what they’ve done in the past. The industry works with at least one large PR firm—this time it’s Forbes Tate—to help set up and run an organization they refer to as the coalition. The name of the current coalition is the Partnership for America’s Health Care Future. I call it a front group. They’ve had different organizations in the past that have served as their hub for pushing back against policy change. The first one I was involved in when I was with the industry was during the Clinton era, when Hillary Clinton was leading the effort to reform the health care system. The hub then was the Healthcare Leadership Council. They’ve used different organizations, different vehicles over the years, but a central part of the strategy is to have one place where they can throw money at it, and wage a propaganda campaign against reform, whatever form that might take.

The campaigns to defeat health care reform in the Nineties were straight out of the tobacco wars. The PR firm APCO Worldwide was hired by Philip Morris decades ago to discourage lawsuits against the tobacco industry, and they set up front groups, or CALAs for short, for Citizens Against Lawsuit Abuse, to make people think that lawsuits were completely out of control. We hired them during the campaign against the Clinton health plan to reactivate those groups. In the late Nineties, there were class-action lawsuits brought against the big insurance companies on behalf of doctors, and there was another wave of lawsuits on behalf of patients. We used the CALAs to try to persuade judges, and the public, that the real problem was this litigious country of ours, that people were filing frivolous lawsuits. God, how many times did I use that term? I haven’t seen it in the headlines in this debate much yet, but just stay tuned.

As a professional, how would you assess their performance so far in the current campaign?

I would assess it as pretty formidable, because they’ve got almost unlimited resources. The campaign strategy is multifaceted. One central technique that they’re using once again is to instill fear of change. There’s an acronym, FUD, which stands for fear, uncertainty, and doubt. All of the campaign messaging will be FUD-based. The intent is to persuade people that what’s being proposed is not in their best interest, to get them to fear change, and to get them to think that the current structure, while not ideal, can be tweaked, that we can build on the existing framework to get where we need to be.

How much of the industry’s strategy do you see reflected in positions and messages of various Democratic candidates?

I’m absolutely seeing the influence of the industry. What candidates aside from Sanders and Warren are proposing would be less disruptive, allowing the status quo largely to be maintained with a few notable changes. They’re trying to moderate their positions with a message that we can get where we need to be by either adding a public option, or by doing this or that to advance the ball toward victory. I think they’re doing this largely because some of their advisers had connections to the industry in the past.

It may be unfair to single him out, but Pete Buttigieg certainly had a lot of people from the industry, particularly from the pharma side, holding fund-raisers for him. Do you see the turns of phrase he uses, or any of the candidates use, as echoes of what the coordinating group would be crafting?

Absolutely, I do see influence on his messaging, what he’s saying, using it as talking points, and essentially saying what they say—“they” being the industry. They would say, or they would try to get us to believe, that the current system is the best in the world. We just need to have a tweak here and there, institute a public option, for example, to give people more choice. That is also a part of the industry messaging. They often will use the word “choice,” because they know that term is one Americans react positively toward, that we see ourselves as a country built on capitalism and choice and competition are part of our DNA. So the industry, the insurance industry in particular, wants to make people think that what Americans desire is choice of health insurers, and that’s something that needs to be protected, and that our employer-based system is sacred and needs to be protected. Regrettably, you’re seeing Buttigieg and other Democrats, including Kamala Harris, buy into that. What Buttigieg is proposing would allow the employer-based system to largely continue, and leave the system of multiple insurance companies in place, just adding one more element, which would be a public option that would be government financed, as was part of the debate ten years ago.

So what’s wrong with going with a public option?

At the time of the debate over Obamacare, I thought, “Well, that would be the best we do. It might be helpful to people if they had a public option.” I’ve since come to the conclusion that it would just add to the complexity and confusion. People often make mistakes when they choose a health plan, and that complexity and confusion benefits the industry. I don’t believe that a public option would really be helpful in the long term, but Buttigieg seems to have bought into that.

The industry isn’t supportive of a public option, but they certainly see that Buttigieg’s candidacy is trying to throw shade on Medicare for All, and that’s helpful to them. They have to be overjoyed that Buttigieg and Harris are saying the things they’re saying.

Buttigieg, and a lot of others, like to repeat the phrase “kicking one hundred and fifty million Americans off their health plan.” That sounded to me like something that must have been the product of an industry-sponsored focus group.

It is, absolutely it is. It’s clearly a focus-group-tested phrase, and like I said before, it’s playing on people’s fear of change. It also obscures reality, and shuts down—or the attempt is to shut down—debate on how to really change our system in ways that everyone would benefit from, everyone except maybe the entrenched special interests. That absolutely is a phrase that comes straight out of the insurance industry. It’s designed to scare people, and Buttigieg, by design or unwittingly, is using the same talking points that the industry wants people to hear. One way or another, he’s really carrying water for the insurance industry, as are others. Certainly Joe Biden and Amy Klobuchar.

Apart from Buttigieg, Harris, and others, we also have Congressman John Delaney, a former health executive, in the running.

Anyone who has been an executive and made money in the health care system, I’m skeptical of their point of view.

What about the panelists in the debates? Do you see the hand of your old employers in their questions?

I sure do, and it’s not a bit surprising to me. In my old industry job, much of my time was spent figuring out how to influence reporters and others in the media. One way was to develop relationships with them, to get them to see me as a good, trustworthy guy. That enabled me to shape the stories they would write in subtle and sometimes not so subtle ways. One of the subtle ways was to get them to adopt the language, the framing we used. And when our language, our framing, is repeated over and over again, it becomes the language the media and politicians and the public use. Debate moderators have been, maybe unwittingly, using the language the industry prefers, asking questions the industry wants to have asked. They’ve also avoided asking certain questions. The moderators are largely letting the industry off the hook.

Meanwhile, Sanders and Warren have been under fierce attack for their positions on health care. How would you assess the way they’ve defended themselves?

I don’t think they have made the economic case well enough to the public about why this is the way to go, why the current system is unsustainable and why some of the ideas espoused by Harris, Buttigieg, Biden, and Klobuchar would just be applying yet another Band-Aid to a system that’s fundamentally broken. So I think they’ve got more work to do.

They need to explain to the public how, over the course of the past several years, people have been paying more for coverage that is less and less valuable and more and more restrictive. The industry would prefer that you think that what people really want is more choice of insurance company options, but that’s not the case when you look at the polling. What people want is to make sure that they have freer access, and unlimited access to the health care providers of their choice—meaning doctors, hospitals, and other facilities. I think that Warren and others need to help the public understand that competition absolutely does not work in health insurance—or health care period. But let’s stick with health insurance. The more health insurance companies you have supposedly competing in a given market, the less ability any of those companies have to really negotiate with large hospital systems, for example, or drug companies.

What other themes are the industry pushing? 

A deliberate misdirection is that they would like for us to believe that the ultimate goal is universal coverage. We need to have everyone covered, but you simultaneously have to have a system that controls health care costs. We made some advances under the Affordable Care Act to get more people covered, but the downside is that, increasingly, people are in plans that leave them underinsured. That is certainly true of people who buy their coverage through the Obamacare exchanges. According to research by the Commonwealth Fund, about 30 percent of people who get their coverage through those exchanges are underinsured. They are enrolling in plans with high deductibles, and most Americans don’t have enough money in the bank to cover the deductible, so they’re underinsured.

There are so many different ways that insurance companies can devalue your insurance plan. I don’t think Buttigieg, Harris, or the other candidates are fully aware of the tactics the insurance companies use to avoid paying for care.

So someone, or some committee, said, “Let’s push the debate in this direction.”

They want us to focus exclusively on the quest for universal coverage. During the debate on what became the Affordable Care Act, there was this almost single-minded focus on getting people covered without any thought about how good their coverage would be. And we’re finding that, increasingly, it’s not very good. I was doing some research the other day, because I’ve talked and written recently about the roles that I’ve played in helping to defeat the Clinton health care plan in the Nineties. Back then I saw a report that was in Health Affairs, I think, that the average cost of a family plan through the workplace was less than five hundred dollars. It’s now more than twenty thousand five hundred dollars.

Wow.

When you’ve got health care premiums going up that much, even premiums from the workplace, from employers, that should be all the empirical evidence you need that private insurance companies cannot control health care costs. We’ve been sold a bill of goods by this industry for decades, and I think employers are beginning to wake up. They cannot rely on the private insurance industry to make it possible, to make it sustainable, for many of them to continue offering coverage.

That’s why I lead this organization called Business for Medicare for All. More and more employers are throwing in the towel. One hundred and sixty-four million Americans get their coverage through their workplace. That number is large, but when you look at it as a percentage of the population, there’s been an overall decline in working-age Americans who get their coverage through the workplace since the late Nineties. It’s diminishing because the companies they work for are increasingly unable to offer coverage. Yes, the largest ones still do, and the midsize ones are still mostly offering coverage, too, but they’re struggling. They’re all struggling because of these unrelenting rate increases they’re getting hit with.

You say that the insurance industry cannot control costs, but are they actually interested in controlling costs?

No, they’re not, and that’s something that’s also been obscured by this debate and by the industry’s propaganda campaign. They don’t want to in any meaningful way, because as costs go up on the provider side—whether it’s higher bills from hospitals, drug companies, or physicians—they’re able to raise premiums to cover whatever medical inflation there is. They have developed tactics to avoid paying for our care by raising deductibles, or requiring prior authorization, or creating limited networks. That’s the game that’s going on, and that’s the game I hate.

Going back to when you worked on the anti-Hillary campaign, was there any particular successful initiative you came up with or worked on?

I was involved with a trade group at the time called the Health Insurance Association of America, and it was this organization that financed a series of TV commercials featuring a fictional married couple named Harry and Louise. Talk about FUD campaigns! You had this couple sitting around their kitchen table, fretting about what they heard was being proposed by the Clintons. Much of it was just completely made up to scare people, and it was successful. You can easily make people fearful of change, and the industry knows that, particularly if you’ve got lots of money to spend on a clever campaign based on false assumptions. And if you repeat it often enough, you get people to believe it.

You’d jumped ship by the time the Obama debate came around, but were the same sort of tactics, stratagems, and techniques deployed?

Absolutely. There were multiple reasons why I left my job. I knew that if I stayed, I was going to have to continue to do the same kind of work, the same propaganda work, the same work to equip our lobbyists with messaging to push back against reform, and I just didn’t have the stomach to do that anymore. I knew that if I stayed, I was going to have to continue to be a cheerleader for the status quo. That was one of the reasons that I left, but yes, I saw taking shape the exact same thing that happened during the debate over the Clinton plan, and we’re seeing it again right now. The strategy is identical. It’s for these big, entrenched special interests, whether we’re talking about insurers or providers, to pool their resources, because they’re making money, and a lot of money.

Clinton’s health care effort went down to defeat; Obama’s was a draw. How do you see Medicare for All turning out?

I see this turning out differently. I’m an optimist. I wouldn’t be doing this if I weren’t, and if I didn’t believe Medicare for All was achievable and the right policy. I often say it’s a matter of when, not if. That’s because the current system is not sustainable for any of us, and that includes our businesses. Warren Buffet has said that our health care system is the tapeworm that’s destroying American competitiveness. He’s absolutely right. As more and more business leaders join the effort to ditch the current system, we will see more and more policymakers begin to embrace Medicare for All. It will happen.