Can Knutson Cure N.D.‘s Ailing Health Care?

It’s been 30 years since he became the most visible victim of the Great North Dakota Health Care Measure Massacre. But former North Dakota Insurance Commissioner Byron Knutson is still on the case.

For those who need a refresher, or simply weren’t around a generation ago, 1978 was like most any other off-year election in North Dakota, with one huge difference: ballot Measure 4, the health care initiative.

The lengthy initiated measure—rather modest compared with current proposals for health care reform—authorized a comprehensive review of health care costs by the legislature with the goals of implementing local control, enlarging state oversight of health insurance providers to keep premiums affordable, and altering the makeup of the North Dakota Health Council. Significant changes, to be sure, but not really bomb-throwing stuff.

In the 2008 election, the need for health care reform was such a given that even John McCain disagreed with the Democrats only on what kind and how much national health insurance the country should have. As early as 1992, Bill and Hillary Clinton felt the time and tide were right to shift at least some of the responsibility of health care insurance to the government.

But the past is another country. And another state. And it was in North Dakota, circa 1978, that a populist insurance commissioner attempted to affect a similar shift. Instead, the shift hit the fan.

“We knew we would be outspent” said Knutson. But he and other advocates for the measure admit they weren’t braced for the Tet Offensive opposition forces threw at them.

To wit: In short order the major insurance companies operating in the state linked arms with the American Medical Association (AMA), nurses’ unions, and sundry medical associations to lobby against the measure. Blue Cross Blue Shield of North Dakota and the Greater North Dakota Association made defeating the measure their priority. The AMA and American Dental Association both allegedly sent representatives into the state to train doctor’s office managers and receptionists how to persuade patients against the measure. And health care employees—from doctors to hourly workers—had paychecks dunned to finance a blitzkrieg of advertising and lobbying against it.

On top of that in-state war chest, advocates for the measure estimated (and the other side didn’t seriously dispute) that at least $1 million—in 1978 dollars—of outside money rolled into the state to convince us Measure 4 would result in increased medical costs, as well as fewer and poorer services, longer waits and the great sucking sound of thousand of doctors deserting the state for more welcoming climes.

On the other side, according to veterans of the campaign, the insurance commissioner’s office spent about $1,000 promoting the measure with no visible private spending with the same goal.

Knutson recognizes that politics is a game of winners and losers in the court of public opinion, and he doesn’t hold a grudge.

“You can’t blame it all on the opposition,” he said. “They have their rights just as we do, and they have to do their work.”

On the supporters’ end, he said “we likely would have had a stronger finish if we’d had a better system of distribution” for their own materials, speakers, etc.

Knutson was insurance commissioner at the time and the godfather of the measure. He and office staff wrote the measure and midwifed it onto the November ballot. He regarded the changes in the measure as growing naturally out of his public obligation.

“Every movement and every cause needs a spokesman,” said Knutson. So, he naturally became the face behind the measure, and his prairie populist persona became inextricably woven into the autumn melodrama.

The measure and its intent may seem prescient, but Knutson said he was actually looking backward, basing the measure on a failed health reform initiative Harry Truman sought in 1948. He also used the government single-payer insurance plan he had observed in Saskatchewan, where his wife Bernice has relatives, as a model.

“Single-payer health insurance” is so devoid of controversy that it’s almost a platitude for pols today, and Michael Moore has helped popularize Canada as an oasis of government benevolence, but back then the Saskatchewan lineage sparked unending he-said-she-said arguments about whether provincial or federal health care in Canada really rocked or really sucked.

Knutson sided with the former, and continues to. “People don’t believe it, but it’s amazing,” he said about how little bureaucracy patients encounter in Saskatchewan clinics and hospitals. In an Estevan hospital, for example, he said an administrator told him paperwork for a patient “was one page: one half for admission, one half for discharge.” And administering Saskatchewan’s plan only eats up 2 to 3 percent of total health costs, he claimed.

Knutson stood out from the other Democrats. An old-school NPL’er (Bill Langer division) he grew up in Harlow, then juggled a railroad career as the agent-operator of several small train stations with Korean War combat in the Marines and two terms, 1958-1962, in the North Dakota House.

After retiring from Soo Line in 1970, he moved Bernice and their two daughters to married student housing at UND so he could pursue his masters in political science. But politics beckoned again, and he closed his books to campaign unsuccessfully for seats in the state House in 1972 and the Public Service Commission in 1974.

Unfazed by defeat, he picked himself up and got back on his horse, this time to run as the Democratic nominee for insurance commissioner in 1976, despite having no experience in the insurance industry on his resume. And this time he won in an upset over favored Republican Bud Wigen

Knutson practiced his belief that his office was there to serve everyday folks with problems and made it a point to keep himself accessible. As an office holder, he said: “I’m satisfied that I did what I wanted others to do.”

He has adopted, almost as a personal mantra, the famous tenet of the Nonpartisan League that “we believe in social and economic justice for all and special privileges for none.”

Almost religiously pro-union in a right-to-work state, Knutson took evident pride in practicing a brand of retro-populism that Democratic office holders had largely abandoned. He made it a point to tell reporters he took his oath of office in a sports coat which cost him 75 cents at Goodwill. News media found him to be a colorful and refreshing break from the suits in Bismarck but not really a player. He was a maverick before maverick was cool.

Of course mavericks can make enemies within their own camp, and that was true in spades for Knutson. Some of his fiercest detractors were fellow Democrats, who saw him as too plain spoken—ready to speak first and think second. It didn’t help that occasionally his conversation became a stream-of-consciousness sentence James Joyce couldn’t follow (even his most sympathetic listeners mentally screamed for him to put a period on it).

Despite his energetic statewide campaign for the office, many critics stoutly averred that he only won because voters who hadn’t met him were seduced by his good Norsky name on the ballot.

Already under skeptics’ scrutiny upon taking office, he promptly cultivated controversy by staffing key secondary positions with a cadre of young Turks and veteran grassroots Democratic activists who shared his passion for reforming the way insurance companies did business in North Dakota, but they mostly also shared his inexperience within the industry.

Tracy Potter worked as his life and health analyst and a chief aide and was primarily responsible for drawing up the initiated measure and engineering its journey to November. The nuts and bolts of writing the measure took “a month of 80-hour weeks,” to get it out of the office, he said, but only two and a half weeks to get it back with the necessary 12,000 signatures to meet the August filing deadline. An early poll showed 56 percent voter approval and only 20 percent opposed with the rest undecided.

Potter is currently on leave from his job as director of the Fort Abraham Lincoln Foundation, Mandan, to serve his first term as a North Dakota senator. But he recalls his time as one of Knutson’s raiders as “kind of a wonderful place to be back then.”

“We really felt we were fighting for the little guy,” he said. Also, he added that they went into the ballot fight “still believing all things were possible.”

He knows better now. It may be that the positive forecast of early polling awakened the sleeping dragon of the opposition. After all was said and done in the fall campaign, and a lot was, the measure failed at the polls by at least three to one.Chalk that one up for the big guys.

When Knutson lost re-election in 1980 in a revenge match with Bud Wigen, Potter returned to UND to earn his masters in history. His thesis, on file at Chester Fritz Library, was his own account of the rise and fall of Measure 4. Its nicely nonacademic title is “Stirring the Hornet’s Nest.”

Knutson is sanguine about the slings and arrows he suffered during that campaign, but he occasionally admits they got to him. The vast (for North Dakota) right-wing (well, conservative anyway) conspiracy which arose to say “this (measure) shall not pass” found political profit in attacking him personally.

Knutson became a target of scrutiny from N.D. media. “I think they [state newspapers] rode the hell out of us,” Knutson said in what for him is an uncharacteristic burst of strong language. The personal attacks “kind of hurt,” he admitted, and “the cartoons were pretty rough.” But, as if afraid to sound self-pitying, he quickly added “we’re not the first ones to receive that kind of treatment.”

He sees the real victim as the issue’s display place in the marketplace of ideas. “There was a lot at stake for us; this was an issue we should have public discussion on.”

“Some of these things can be demagogued to death,” he said, and the kind of issue-ad spending he encountered likely drove the stake though the measure’s heart.

Potter is slightly readier to look back in anger. The opposition “was really, really kind of vicious” he said. “It was overwhelming.”

“In the end Measure 4 was beaten because the other side had plenty of money to mischaracterize it,” he added.

They felt they were fighting the good fight, Potter said, but in hindsight he admits that “I don’t know if we advanced the cause of health care or not.”

After leaving the insurance office in 1981, Knutson was not about to retire from politics. He mounted an unsuccessful campaign for the nonpartisan office of labor secretary in 1982 and a signature campaign for the Democratic nomination for secretary of state in 1984, a move that unseated the party’s chosen nominee, doubtlessly bolstering his maverick rep and making still more enemies within his own party. He lost in November. In 1986, however, the labor office was again up for grabs, and 10 years after taking his oath as insurance commissioner, he raised his hand to take over the labor office. He left it in 1991.

What makes Byron run? To help, he said. Citing another passage in the NPL charter, “the solution to ... problems can be found at the ballot box.” He is convinced one of these solutions will be single-payer health insurance, and he tells people that at the drop of a hat.

That hat drops a lot, as it happens. He and Bernice fill their empty nest retirement years with his appearances addressing health care groups, seniors groups and unions in North Dakota and Saskatchewan. They continue to spend time at Kennedy Center in Bismarck, working for the Democratic Party, but now like to spend more time with their grandchildren. Their two daughters both carry the banner as party activists.

Like Potter, Knutson is ambivalent about the fate of Measure 4, saying they may have tried to do too much too soon. “Most of the changes to the health care system seem to be ... on an incremental basis,” he said.

With 30 years to get more used to the idea, could a reincarnation of his measure pass these days? “The chances of seeing it are pretty slim,” he said, “but then so was having a black man take the oath as President.”