PERSPECTIVE ON NATIONAL HEALTH : Political Handcuffs Hobble Debate : All agree that medical insurance is a mess, but political constraints have skewed the debate on solutions.

American medical care, we are regularly told, is in serious trouble. Costs are too high, access and quality too variable. There is relentless incantation about our $700-billion-plus medical industry, consuming more than 12% of our GNP while failing to insure 37 million Americans. Most of the rest of us are one illness or one job loss away from being medically uninsurable. These statements of alarm emanate from all parts of the political spectrum. Even the conservative Heritage Foundation has declared that “America’s health-care system is on the critical list.”

Unfortunately, it is not clear that this extraordinary agreement--across lines of party, occupation, income, region, and age--will produce effective policy reform. For while consensus permits (and may even generate) reform, it does not guarantee any particular remedy. And, unfortunately, the remedies chosen are likely to reflect the current constraints on political action as much as our critical need for health-care improvement.

Our political system alone makes the process of legislative change difficult. It is designed for slowness, not action--as every civics book explains--with myriad and conflicting governments (federal, state and local) and an abundance of policy entrepreneurs. The result is many proposals and no agreement on which ones to enact.

What our institutions make difficult, our ideological leanings make even more so. Historically, Americans have been ambivalent about government, turning to it in dire need (the Depression, world wars) and spurning it in times of greed (the 1920s, the 1980s). For the last two decades, our most prominent leaders have stressed government’s liabilities, not its capacities, and the media have amplified this mocking. One result has been erosion of American confidence that public institutions can right the obvious wrongs of American life. Another result is that reformers in a problem area like health care are powerfully constrained in what they can propose without unleashing propagandistic attacks.

For instance, right-wing public-relations and polling experts have a well-developed response to proposals for a national health insurance plan modeled on the relatively successful Australian, Canadian or West German examples. “If you like the post office,” they say, “you’d love national health insurance.” Another version of this theme argues, “If you think the Pentagon’s $700-toilet seat is wasteful, wait until you see government health insurance.” The same propagandists go on to all manner of false and frightening images of “government medicine”: Canadians dying while waiting for emergency care, Germans tied up in bureaucratic messes, the socialistic excesses “down under.”

With the S&L; scandal fresh in the minds of our politicians, no wonder so few have responded by reminding Americans that our Federal Reserve system is corruption-free or that our Social Security Administration regularly gets its job done with reliability, accuracy and efficiency.

Our candidates for office uniformly feel compelled to avoid the label of “socialized medicine”; some genuflect toward “private provision of care,” conceding that competition must be part of the medical-care answer. These are the misleading liturgies that our ideological climate practically forces on cautious reformers.

Finally, we are led to believe that we apparently cannot finance medical reforms with “tax” dollars without the prospect of an anti-tax revolt. This constraint--brought to us by Ronald Reagan and now part of the conventional wisdom--means that new program financing, to have any chance of passage, has to be hidden behind some sort of fig leaf--”mandated employer health insurance,” for instance.

What does this combination of agreed-upon problems and political constraints produce? So far, not much. The most widely discussed reform proposals--advanced by both Democratic and Republican leaders--combine bold rhetoric with timid policy. These plans would require every business to either provide insurance for its employees or pay a premium into a public fund (which would also cover Medicare and Medicaid recipients). The schemes all have different monikers--Sen. George Mitchell’s Health America is the most recent--but “pay or play” is the general descriptive slogan. They all seek to avoid the appearance of taxation and duck a clear statement that single-payer government health insurance--not shoring up a failing private insurance system--is what’s required. Yet it is these plans that have attracted the most attention just when universal health insurance has finally arrived at the top of the domestic agenda.

“Pay or play” is a misleading financial and athletic metaphor that confuses more than it clarifies. Offering employers a choice of private or public plans ensures that the government program will attract the worst risks and hence incur the highest per-capita costs. Implementing such programs will lead not to stability but to a sharp division between the “more expensive” government program and the “less expensive” private one. And despite all the talk about mandatory cost controls, the use of our present insurance apparatus will perpetuate the intrusive, complicated and costly administration that so bedevils us.

Practically all of the political leaders who have given us this flawed “pay or play” option are intelligent and well-intentioned. It is our institutional arrangements, our ideological inclinations and the operation of political money and organizational self-interest that have convinced them that what is really desirable is not doable. But effective and acceptable alternatives are out there, if only our leaders could look forward rather than backward.