President, Public May Differ Over Health Reform Goals

Greg Levish, a steelworker, recalls that after a sinus operation a few years ago, his doctor sent Blue Cross a bill for $1,200. When the insurer balked, the doctor settled for $300. That was enough to persuade Levish that government should prevent doctors from inflating prices.

Joe Kula, who lives with his wife on a fixed pension, tells how he spent $600 last month when he went to the pharmacy to fill the prescriptions he needs for his many ailments. He wants the government to regulate the rising pharmaceutical costs that are squeezing his small income.

Kathy Voltz, mother of five children, notes that her insurance has paid less each time she has delivered a baby. Preferring to stick with the doctors she has gone to for years, she refuses to switch to a cheaper health maintenance organization or managed care plan. She wants the government to control insurance prices without disrupting her freedom to choose her own doctors.

Levish, Kula and Voltz are all looking to President Clinton’s promised health care reform plan to answer their complaints. But they are likely to be disappointed. Like a majority of Americans, the people of this working-class community may soon find that what they want from reform differs in significant ways from what Clinton plans to deliver.

While a recent study shows that most Americans would like to see the government crack down on what they view as the inequities and profiteering inherent in the current system, the President’s health specialists are talking instead about imposing a new health care plan that would limit medical expenditures and ration care.

“There is a major difference between what the public sees as the problems of health care and what the experts believe,” observes Robert J. Blendon, professor of public health at Harvard University. “The public complains about being billed $5 for an aspirin; experts think we use too many aspirin.”

There is no polling data that precisely compares popular support for the health care plan Clinton is likely to deliver and the kinds of increases in government regulation that many people seem to favor. But in a study of several polls published recently in the Journal of the American Medical Assn., Blendon and other experts reported that only 28% of those surveyed chose the kind of plan Clinton has espoused among several alternatives.

Fifty-two percent said they favored government regulation of doctors’ and hospitals’ fees, while only 41% expressed support for managed competition, the free-market approach that is favored by Clinton.

Under managed care, consumers are asked to chose a primary care physician who has a contractual relationship with the insurer. That doctor receives a set amount of money to provide treatment and then serves as a sort of “gatekeeper,” deciding what care each patient should receive. Since the amount of money doctors receive is fixed, they will have a direct incentive to avoid unnecessary treatment, proponents of managed care say.

To the experts, health care costs are skyrocketing, in part because too many consumers are sticking to old-fashioned doctor-patient systems and at the same time demanding expensive, new technological advancements in medicine that they do not necessarily need. To cure this problem, they are proposing to restrict care and reserve the most sophisticated procedures for those judged to be the sickest and most likely to benefit.

To laymen, on the other hand, health care is becoming increasingly unaffordable because of what they view as the greed of insurance companies, doctors, hospitals and pharmaceutical companies. They want the government to regulate prices and maintain fairness but without disrupting the current health delivery system--except to extend it to those not covered now.

“People see the inefficiency, the unnecessary procedures, the administrative waste,” notes Rhoda Karpatkin, president of Consumers Union. “People have a very strong sense of the injustice of it.”

For Clinton, this difference of opinion between the experts and the public poses a real challenge. Unless he can resolve these conflicting points of view by the time he unveils his reform package later this year, political and health care experts say it will be virtually impossible for him to achieve broad support for his proposal.

“We ignore these public attitudes at our peril,” warns Thomas Langfitt, president of the Pew Charitable Trust, who spoke at a recent conference attended by the President’s top health care adviser, Hillary Rodham Clinton.

Already, the President is making some efforts to persuade the public that he shares their jaundiced view of the medical establishment. He promised during his campaign that he would “get tough” on insurance companies. More recently, he has lambasted the pharmaceutical companies for profiteering.

A public opinion poll conducted last year by the Employee Benefits Research Institute found that while 61% of those surveyed believed their health care needs are being met, 85% rated the overall system as in need of reform.

Yet the President’s reform plan--like his economic plan--is likely to demand as much sacrifice from consumers of health care as it does from doctors, hospitals, insurers and drug companies. And that is certain to upset those Americans who say they are generally satisfied with the medical care they now get.

The Clinton Administration and the American public are perfectly in sync on some essential elements of health care reform. Even though most people think that they are getting good care, they recognize that the system has been dangerously imperiled by rapidly rising costs.

Like Clinton, most Americans--even those who receive good health care themselves--have told the pollsters that they believe health care must be guaranteed to the more than 35 million people who are without it.

Likewise, in dozens of interviews with the citizens of this mill town along the Allegheny River on the outskirts of Pittsburgh the sentiment in favor of a system of universal access to health care was overwhelming.

“Health care ought to be a right,” declares Craig Campbell, whose health insurance was canceled Jan. 8, the day he was fired from his job. “It should not be limited in any way.”

Irene and Ivan Longdon, both school bus drivers, are typical of most low-wage workers who cannot afford health insurance. They lost their Medicaid recently when one of them got a tiny pay increase; they cannot afford the premiums for private insurance.

“We’re scared to death one of these days we’re going to end up in the hospital,” said Irene. “Talk about sweating it!”

Even many people who said they have health insurance want the government to provide it for the uninsured. Some clearly fear they might lose their insurance someday; others have seen relatives and friends suffer without health insurance.

“If it hasn’t happened to you, you are afraid that it will, and that is very anxiety producing,” says Karpatkin. “People also say, ‘I’m all right, but it is not fair that other people are not all right.’ ”

Those who lose their benefits discover that private health insurance is often prohibitively expensive. Campbell says he was told he would have to pay $728.52 a month to buy insurance equivalent to what he had before losing his job.

Melissa Elliott, 32, who works at a rental shop, recalled that her uninsured brother recently suffered a fractured ankle for several weeks before he finally sought treatment. She said that an uninsured friend had to save up $2,000 before an obstetrician would agree to deliver her baby.

“Thank God my husband has insurance,” says Elliott.

But Clinton’s plan for insuring the uninsured could bring hardship of its own. The Longdons fear that they will be fired if the government forces their employer to contribute to their health care, as the President has proposed.

Likewise, Joan Gentile, 31, owner of two small grocery stores here, says she could not afford to pay even $100 a month to provide coverage for all seven of her employees, only one of whom now gets health benefits.

“It probably would wipe us out of business,” she says. “There is not a high markup in groceries. We only make 5% on a bottle of milk.”

While many people here cite rising costs as a primary reason for reforming the health care system, cost-cutting does not seem to be as important to them as providing coverage for everyone.

Experts note that most Americans who are covered by health insurance do not know the true costs of care. Indeed, none of the people interviewed here--except those who are self-employed--knew how much money their employer spent to provide them with health benefits.

Surprisingly, though, many people say they would be willing to pay a modest increase in their taxes to help provide coverage for everyone. Some even suggested imposing new taxes on cigarettes and liquor, gasoline or the health benefits themselves.

“If I could be assured the problem could be solved, I would be happy to pay more taxes,” said Pat Burchell, 55, who works at Dynamite Day Care.

A study of public opinion published recently in the Journal of the American Medical Assn. shows that as many as half of American voters would pay an additional $20 a month for a universal coverage plan. More than three-fourths of the population would support higher cigarette and liquor taxes, and more than half would support a tax on health benefits.

Some people clearly understand that their own health insurance already is paying for care of the uninsured through the widely recognized practice of cost shifting by doctors and hospitals. “We’re paying for it anyway, so why not pay higher taxes,” shrugged Sheila Trenski, 57, a self-employed deli owner.

Clinton has made no final decision on how he will fund his health reform package. Under consideration are a variety of measures ranging from cuts in Medicare and Medicaid benefits to an elimination of the current tax exemption for employer-provided health benefits.

Although organized labor opposes taxing health benefits, none of these proposals draws as much opposition in Brackenridge as the idea of cutting Medicare benefits. The plight of pensioners like Kula is well known in a Rust Belt town like this, where senior citizens are a strong political force.

“Every time my medicine goes up, my income goes down,” said Kula.

None of the people interviewed for this story was familiar with Clinton’s campaign proposal for health care reform, even though some said they had voted for him because they expected him to improve the health care system.

Many people here are still under the impression that the Administration plans to impose a Canadian-style system of national health insurance. Such a system is particularly appealing to those who want the government to set doctors’ fees and regulate drug prices.

The Employee Benefits Research Institute survey found that Americans are confused about the options being discussed by the experts. While nearly half of the population thought employers should be responsible for providing coverage, 68% favored a Canadian-style government-run system.

Harvard’s Blendon noted that most Americans cannot sort out how they would fare under any of the alternatives. “People say: ‘I don’t know how these plans will affect me. Will I have a big co-pay? Am I going to be better off?’ ”

A recent study of several public opinion polls by Blendon and his associates found that the population is evenly divided between two options: the managed competition model favored by Clinton and simple government regulation of fees paid to doctors, hospitals and pharmacies.

To most people, terms such as “managed competition” and “global budgeting,” which are the pillars of the plan that Clinton proposed during his presidential campaign, might as well be a foreign language. In general, the system would rely on competition and spending caps instead of price regulations to keep costs down.

Many local residents are familiar with the concept of managed care, which Clinton’s plan is expected to promote. Employers here already are offering managed care as an option.

But like Voltz, who prefers traditional health insurance, most residents interviewed say they do not want managed care because it might prevent them from continuing to consult their own doctors and limit access to specialists.

“I want to be able to choose my own doctor,” insisted Jeanie Nesbit, 38, a steelworker and a union activist. “I don’t want anybody telling me what doctor I’ve got to go to.”

The power invested in the primary care physician under managed care is a feature that disturbs those people who believe they were misdiagnosed by general practitioners.

Jack Richards, 44, remembers how local doctors thought his 7-year-old son, Caleb, had a growth disorder. It wasn’t until he took his son to a specialist in Pittsburgh that he learned the boy was perfectly normal.

Likewise, Trenski recalls that her brother’s personal doctor found nothing wrong with him after a bout of severe chest pains. But when he consulted a specialist, he was immediately rushed into surgery for a bypass operation.

While health care experts believe Americans consult too many specialists, the people of Brackenridge seem to believe it ought to be their right to get expert care when they want it. In their view, the problem is that the specialists are charging too much money.

“Doctors out there are getting rich by prescribing some type of treatment that didn’t need to be done,” says Nesbit. “I know they are skilled,” adds Trenski, “but why do they need those multimillion-dollar houses when other people don’t have a place to sleep.”

According to Blendon, opinion is evenly divided on the issue of global budgeting, or capping the amount of money the nation can spend on health care each year. But support for global budgets falls below 30% when people are asked if they would wait in a line longer or travel farther for care.

To most Americans, the primary criteria for judging any new health care plan will likely be fairness. “It has to be viewed as a net gain and, most of all, fair,” says Karpatkin. “I don’t think they will accept an unfair system.”

Many people in this community seem to harbor a suspicion that whatever Clinton proposes, it will somehow provide better care for the rich than for the working class. As James Waters, 48, a steelworker asked bluntly: “Is some millionaire going to get it before me?”

Clinton’s staff has been advised by Blendon and others that they must take these fears and preferences into account as they draft a health care reform plan or they risk igniting a firestorm of opposition around the country.

“My message to the political leaders,” says Blendon, “is that you either need to change the public perception or you need a plan that pays attention to public concerns.”