Health System Activism Joins Campaign Trail

When New Hampshire voters finish casting their ballots in the nation’s first presidential primary next February, they will emerge to face a bewildering assemblage: TV cameras, researchers taking exit surveys--and health crisis activists.

Video cameras and pollsters are standard props for election-year benchmarks such as the New Hampshire primary, but the activists will be a new element. Health Care for America, a recently organized lobby group dedicated to pushing comprehensive health care legislation, will be busy gathering signatures on petitions urging Congress to enact a major health package next year, hoping to take advantage of Harris Wofford’s victory on that issue in the Pennsylvania senatorial race earlier this month.

Like a broad array of pundits and lobbyists, HCA strategists are confident that health care will be a major issue in the 1992 presidential and congressional campaigns--and on Capitol Hill as well. “Our whole effort is at the grass-roots,” says Harvey I. Sloane, the organization’s founder and president. “The issue is very hot.”

Sloane’s group is not the only one gearing up for increased action on the health care issue. With Congress considering some 30 major proposals to overhaul--or at least patch up--the current system, lobbying activity is shifting into high gear. Organizations ranging from big business and physician groups to organized labor and hospital associations are beefing up their legislative efforts. Dick Davidson, president of the Chicago-based American Hospital Assn., long a major player in the health care debate, is moving his entire personal staff to Washington, partly to position the organization for the coming fight.

Even more surprising to some has been the sharp shift in the stands of some of the major lobbying groups. Organized labor, which helped kill the last major effort at enacting comprehensive health care reform in 1974 by insisting on national health insurance or bust, has softened its approach. It now seems more willing to go along with less sweeping proposals that could prove to be the start of a full-fledged overhaul--including some potentially painful measures to help hold down medical costs.

Indeed, labor as a group is split over which plan to back. Some unions continue to support radical overhaul, while others have said they would be satisfied simply with repairing the current system.

And the AHA and the American Medical Assn., traditionally the staunchest opponents of health care reform, have become newly conciliatory, and far more moderate--reaching out to pro-reform lawmakers as they never have before.

The Chicago-based AMA continues to oppose a government-operated national health care program. But Capitol Hill strategists say that James S. Todd, the AMA’s new executive vice president, has been conferring so regularly with reform advocates such as Sen. Edward M. Kennedy (D-Mass.) and Rep. Pete Stark (D-Oakland) that his presence in their waiting rooms is almost taken for granted--a sharp contrast to his predecessors, who generally used to eschew such contacts.

John Crosby, the organization’s senior vice president for health policy, concedes the AMA has been striving for a new look. “We’re trying to take a much more pro-active, positive approach to this,” Crosby asserts. “We feel we’re at the table discussing what should be on the agenda instead of being on the outside.” Lawmakers say the AHA’s Davidson has made similar inroads on Capitol Hill.

To be sure, the changes do not necessarily signal that comprehensive health care legislation is certain to become law next year. Next year may be the most propitious in memory for sweeping reform--in contrast to previous years, for example, virtually all sides agree that the current system is not working well. But even the most ardent advocates concede that high expectations are unrealistic, at least until 1993, after the election year has ended. Even so, what happens here in 1992 could well lay the groundwork for broader legislation.

Robert M. Brandon, vice president of Citizen Action, which is heading a coalition of 32 organizations seeking a radical overhaul of the current system, admits that Congress is unlikely to take such a sweeping step during an election year, with lawmakers divided--some say splintered--over what kind of measures to approve. “The real issue is to make the election into a referendum (on whether to address health care concerns),” he says.

The complexity of the issue also is a factor. Besides proposals to enact a Canadian-style national health insurance program, there are dozens of competing measures to broaden the coverage of the current Medicare and Medicaid programs and to extend private medical insurance to everyone by requiring employers either to cover all their workers or to ante up a tax to finance medical care for those they omit.

There also are important side issues--such as whether to include coverage for prescription drugs and for long-term care for the elderly, whether to impose limits on consumers’ choices and whether to mandate government regulation of medical prices. And dogging virtually all the major health care proposals is the cost factor: Even the most incremental changes could easily bloat the federal budget deficit--particularly after the first few start-up years.

“There still isn’t a consensus,” says Richard I. Smith, director of public policy for the Washington Business Group on Health, which represents many Fortune 500 companies. “The message from the Pennsylvania election is that the voters want fundamental reform, but I’m not sure we have a detailed-enough message to find out what the voters actually want.” As a result, he cautions, “congressional leaders will need to come to terms” with the disparity when next year’s debate begins.

But there is growing agreement that, fueled by the presidential campaign, the 1992 congressional session will likely lay the groundwork for more serious reform efforts in 1993 and 1994--and may even produce limited legislation next year that could prove an opening step toward more comprehensive health care reform in later years.

Sen. Lloyd Bentsen (D-Tex.), chairman of the Senate Finance Committee, and Rep. Dan Rostenkowski (D-Ill.), chairman of the House Ways and Means Committee, the two lead panels on health care legislation, have unveiled limited plans designed to offer new tax incentives for smaller businesses to underwrite private health insurance for their employees. The proposals also would allow workers to carry over their health insurance coverage after they switch jobs, without having to forfeit coverage of pre-existing illnesses or conditions. Many lobbyists believe that some version of the Rostenkowski or Bentsen plan is likely to pass in 1992.

It also appears possible that lawmakers may enact some version of so-called “play-or-pay” legislation, designed to broaden the current system by requiring employers to provide health insurance for those workers who are not covered now or pay a stiff tax to help the government finance coverage.

Sen. Kennedy, who earlier had sought to create a federally operated national health insurance system, has embraced the play-or-pay approach this year. He and Senate Majority Leader George J. Mitchell (D-Me.) have been telling industry professionals they plan to make it the Senate’s top priority for 1992. Whether they can muster the necessary support, however, remains to be seen.

Understandably, perhaps, the complicated legislative outlook has spawned an equally complex labyrinth of opposing lobby groups--and occasionally some strange bedfellows. For example, physician groups, once solidly against any form of government involvement, are splintered this time around, divided according to specialty. And the AMA and the AFL-CIO, bitter opponents on health care issues in previous years, are finding themselves on the same side on at least one key point: Neither wants to see existing benefits cut.

Unlike the case in most legislative efforts, the health insurance issue is likely to be buffeted--and possibly even slowed--by rivalries among key congressional committees. Although Bentsen’s and Rostenkowski’s panels technically have the major say over health care legislation because they are primarily responsible for congressional action on the Medicare program, Kennedy’s Labor and Human Resources Committee is certain to weigh in heavily on the issue and the House Energy and Commerce Committee is almost sure to proffer its own proposal.

As a result, some analysts predict that the effort to push through some sort of health care legislation could quickly take on the proportions of the Omnibus Trade Act in 1988 or the tax-reform bill in 1986, when some half-dozen different panels in each house demanded pieces of the legislative pie. In those cases, the bills that emerged from the two houses were massive amalgams of proposals from each of the committees. In essence, the real legislation was hammered out in joint House-Senate conference committee--with loopholes that had to be closed later on.

The multitude of fires is being fanned by the rhetoric of the presidential campaign. In the wake of the Wofford victory in Pennsylvania, almost every major Democratic presidential hopeful has placed health care at the head of his political agenda. Democratic candidates have agreed to appear at a nationwide forum on the issue in mid-December. Even President Bush--who earlier had brushed aside the need for comprehensive health care legislation--has promised that his Administration will unveil its own package in the January State of the Union address.

Despite the Democrats’ plans to air the issue in December, most analysts agree that the next major turning point will come in Bush’s address. Although few expect the President to announce any truly revolutionary proposals, he is considered likely to propose credible enough measures to provide a launching point for the debate.

After that, strategists say, the Democrats face a choice of their own--whether to spend the rest of the year denouncing Bush’s proposals as inadequate or to try to hammer out compromise legislation, as they did in the case of the budget agreement two years ago. “My personal opinion,” one says, “is that because of the election you can’t do anything big next year, but there may be some who disagree.”

Once that is decided, there is likely to be another fight--between advocates of more sweeping reform and those championing a more limited patch-up of the current system. “Some people believe that it would be important to have a shootout to get (one approach) out of the way,” says the AHA’s Davidson. “I’m not sure we’re going to see much of anything in the near term.”

For now, all sides--the candidates, the lawmakers and the lobbying groups--are still sorting out their positions and nervously eyeing the various competing camps. Although all six major Democratic presidential candidates have said they will emphasize health care in their campaigns, only one--Nebraska Sen. Bob Kerrey--actually has a specific proposal. House Democratic leaders are still searching for a consensus program to embrace. And lobbyists from the major organizations are quietly meeting with legislators in hopes of getting their opinions heard early in the process. “Nothing really has jelled yet,” one congressional strategist insists.

The AHA’s Davidson says the odds still do not favor enactment of a radical overhaul of the health care system soon, but he cautions that the situation still is in flux.

Major Health Care Proposals

Choices for 1992--or Beyond?

Here the key elements of major proposals to reform the nation’s health care system.

CANADIAN-STYLE PLAN

Physicians and hospitals continue to function as private entities, but government pays all the bills--and regulates prices. Advocated by liberal organizations and some labor unions.

PLAY-OR-PAY

Law would require employers either to provide comprehensive medical insurance for all their workers or pay a stiff tax to help the government finance coverage. Supported by big business, some labor unions and key Senate leaders.

IMPROVE CURRRENT SYSTEM

Improve current system by offering tax incentives to encourage small businesses to extend health insurance benefits to all workers and require insurance companies to allow employees who shift their policies from one insurer to another to receive full benefits even for so-called “pre-existing” conditions.