What is drably called health-care reform is actually social engineering on a scale never before consciously attempted in America. Simply put, we are talking about rewriting the rules for one seventh of the U.S. economy and for most private medical care. The enthusiasts for this sort of experiment routinely remind us that every other major industrial society spends a lower share of national income on health care than we do, while also providing universal health insurance.
True enough. But this rhetoric conveniently omits an inconvenient fact. Most of these other societies are in Europe, where their welfare states-of which health systems are a major part-are suffocating their economies with excessive taxes. We would make a bad bargain if we improved our health-care system at the cost of weakening the economy. That said, our health-care system is hugely imperfect. Spending is undisciplined, because costs are largely hidden. Most workers don’t see the $2,000 to $5,000 their companies pay to buy insurance; Medicare and Medicaid (the programs for the old and poor) are buried in the federal budget. An open-ended demand for health services has inflated spending with a variety of ill effects: more uninsured Americans, as insurance costs rise; depressed take-home pay, because more of workers’ compensation goes to insurance, and a squeeze on other government programs.
The great imperative is to control spending. If we don’t, most of these problems will slowly worsen-even if we create universal insurance. The president has never made this clear. Although he would like to control spending, he also wants generous benefits (mental-health care, drug rehabilitation) for his universal insurance and expanded coverage (drug coverage, more home health care) for Medicare recipients. In the Clintons’ rhetoric, there are no real conflicts between desirable goals.
But, of course, there are conflicts in the real world. If health care is a “right,” where does the right stop? Does it include unlimited treatment for infertility? Depression? Who pays and, if spending is artificially controlled, does quality suffer or rationing result? The Clintons slide over such messy questions, but Congress cannot escape all the conflicts as it drafts legislation (a House subcommittee began last week). To me, major health legislation would genuinely try to control costs and provide some form of universal coverage. There are, I think, at least three obstacles to Congress passing such a bill this year:
In the House, 92 members back a bill to adopt Canadian-like government insurance. Some Republicans support the president’s approach; others favor tax-exempt “medical savings accounts.” The president calls his plan “managed competition” (using competition among medical groups to hold down costs): vet, many advocates of “managed competition” prefer a proposal by Democratic Rep. Jim Cooper of Tennessee. However, Cooper’s plan doesn’t guarantee universal insurance-a point Clinton says is nonnegotiable.
This is a huge undertaking. Alone, many parts of the bill (malpractice reform, drug regulation, long-term care) would be major proposals. Small businesses, doctors, insurance agencies, drug companies-an almost endless list of groups-are already exercised. Some objections are self-serving; others raise legitimate issues. All will create political trouble. In the House, at least 10 committees may write parts of the bill. Conflicts among them would have to be reconciled. Differences between the House and Senate would have to be settled in a conference committee; that would take more time and congressmen want to adjourn in early October to campaign for re-election.
This issue is tailor-made for a midterm election and Clinton’s rhetorical skills. It’s easy to imagine him imploring a crowd: “You need to send me a Congress that will pass the health program we deserve.”
The rejoinder to my skepticism goes like this: it would be politically suicidal to be candid with the public; Congress operates best under oppressive pressure; the Senate Finance Committee has a core of Democrats and Republicans who will craft a compromise from Clinton’s plan, Cooper’s bill and one by Republican John Chafee; when bills get to the floor, members will have to vote for or against-and few will want to face voters having opposed reform. This could happen. Or, Congress might pass modest “insurance reform” that would, for example, prevent insurers from denying coverage based on pre-existing conditions.
OK, no one knows what will happen. But whatever Congress does (or doesn’t) do will disappoint public expectations that have been unrealistically raised by the Clintons. And expectations are at the core of our health-care problem. No one wants to admit the tension between the goals of more coverage and lower costs. Politically, health care resembles budget deficits. We all want someone else to pay for our needs. But health care is harder for two reasons: first, it involves awkward moral issues of treatment: and second, a bad plan could hurt the economy through excessive taxes or employer mandates.
On large issues, the task of political discourse is not simply to pass laws or make programs. It is also to foster a climate of public opinion in which the laws and programs can work, imperfections and all. Health care is such an issue, because it offers only messy choices-not ideal solutions. The Clintons mistake salesmanship for leadership. There are times when people should be told what they need to know and not what they want to hear.
