PERSPECTIVE ON HEALTH CARE : It’s Rube Goldberg, Not Roosevelt : The Clinton plan springs from worthy aims, but fails the first test of practicality--could you explain it to your neighbor?


President Clinton’s proposal for health reform is paradoxical, full of both promise and peril. The Clinton task force has done a remarkable amount of work and the national climate seems ready for reform. Yet the failings of the plan are real, even menacing.

The most telling is its failure to achieve one of Clinton’s most important goals, simplifying American medicine’s stupefyingly complex arrangements. Instead, the President’s plan is a fragile Rube Goldberg contraption.

It’s true that the aims of the plan mirror American aspirations faithfully: security of coverage, control of costs, choice of care-giver and more straightforwardness in what is insured, how it is to be paid for and how disputes are to be settled. But the means to satisfy these aims are literally inexplicable, outlined in a 250-page document with more than 20 volumes of backup material that almost no one will ever read.

The public discussion so far has enhanced the confusion. Information has come out in snippets, scoops and leaks, with practical details mixed into statements of principle like a marble cake.


The content of the President’s proposal is no less paradoxical. Bold in scope and buttressed by consultation with numerous experts, the reform plan itself is very difficult to understand. The problem is not with the goals sought, but with the gap between the aims and the means to achieve them. For instance, the plan promises universal coverage, but not now; it does not assure that America will get better or wiser care, just that the financing will alter and broaden.

The President emphasizes the universality of coverage, putting all Americans in together. But the details reveal that the old are out; so are military veterans, corporations with more than 5,000 employees and even the Indian Health Service. So universality in health reform doesn’t mean all of us, not because the Clintons don’t want inclusion but because they feared more the political backlash of old age, veterans’ and large-business lobbies. This is a critical point. Any plan inadequate for these constituencies should worry us. Hideously difficult as the task may be, establishing common requirements can help to weld these fragmented constituencies together. An adequate plan that can reach and satisfy all of us is what the President should demand.

Simplicity is the Administration’s standard for reform, but its proposal is incredibly complicated--even to understand, let alone administer. Intrusive bureaucracy is this reform’s announced enemy, but the proposal calls for the creation of institutions that have no model in the real world, and assigning them complex negotiating tasks. These are the “health alliances,” a name coined when no one could figure out what was meant by “health insurance purchasing cooperatives.” Making it simple means straightforwardness in design. In the case of the alliances, both the organizations themselves and the proposed formulas for adjusting premiums verge on the incomprehensible.

Perhaps most surprising is the Administration’s paradoxical embrace of federalism, its seeking of the states as partners in health reform. The proposal, according to Hillary Rodham Clinton, is but a framework within which the states can vary. As long as the basic rules are followed, Vermont can go one way (perhaps to a single plan), California another (no doubt to competing plans). This federalist model appears backed-into rather than embraced as a principle; it has not been thought through. But in practice, it would be an extraordinary change in how America’s social-welfare system operates. We do not make a habit of using state governments for universal social programs. We use states for welfare, for programs that poor people use, not programs for all of us, like Social Security. Canada and Australia do employ federalism, specifically with health care, but the Administration has sold this reform as an American answer to an American problem.


So the problem is that we have not addressed seriously the task of making state programs the vehicles of national aspirations. Finding a workable model for this kind of fiscal federalism is too serious a matter to be left to later discussion. On the other hand, this turn to federalism may permit some states to enact straightforward, single-plan, single-payer reform--at the least a useful experiment.

The gaps, the surprises, the paradoxical features--all have political explanations. But whether any of us should consider the result satisfactory depends on how we perceive the balance between the possible and the desirable in 1993. One side of the argument says that if the politically doable is not desirable, don’t do it. If Congress cannot agree on something more straightforward and reliable than the current Clinton proposal, goes this argument, let’s wait. There is more than one way to get workable national health insurance, but all of the models--whether German, Australian or Canadian--are more coherent and simpler to understand. If Republicans want to be a barrier to this sort of coherent reform, concludes this faction, let them be the adversary in the 1994 congressional elections.

The other side argues that if the doable might be transformed into the desirable, there is a case for charging ahead. This would require the Clinton Administration to take seriously the complaint that its health task force took admirable goals and sunk them under incomprehensible and unreliable means. It would mean taking the original aspirations seriously and seeking more workable means. Were the President to take this course of action and succeed by 1994, his performance and reputation would become more Franklin Roosevelt than Rube Goldberg.

The readiest excuse in politics is to claim that what’s right is simply not possible. The least helpful guide to action is insisting on the impossible. Between these extremes lies serious leadership. If it is possible to contemplate rearranging the relationships among doctors, nurses and patients, the Draconian shift that the Clinton plan asks, surely it is possible to argue for other forms of change. The striking surprise of 1993’s health politics is the degree of consensus on the need for universal coverage, portability, cost control and simplification. These considerations argue even for cutting loose from private insurance and cutting loose health insurance from employment.


Given their consensus on goals, citizens at least have a right to insist that any plan enacted pass the simplest tests of plausibility: First, could you explain it to your neighbor? Then, could you assure her that it will improve her family’s health insurance and health care?