Dr. (and Mrs.) Clinton Call for Health Care Surgery : President’s impassioned speech lays out themes of fiendishly complex reform

The buildup to President Clinton’s health care reform speech--and the speech itself--was tremendous, and why not? What this ambitious President is taking on is (depending on which description is used) the most sweeping reform since the New Deal or the most ambitious package of social legislation in the nation’s history. It could also prove to be the biggest flop since the Edsel. But that cannot be allowed, because, as Clinton put it during his televised address Wednesday to a joint session of Congress, this “health care system of ours is badly broken and it is time to fix it.”

OVERHAUL QUESTION: The President is right to want to accomplish health care reform. Every year costs soar--and still too many Americans have no health care coverage. Other nations do so much more with less. Something is not right. In his speech Clinton was doing more than just selling a budget or some legislation. He was attempting to sell change, the catchword that was so pivotal to his election 11 months ago. This proposed change would affect every American in a very personal way indeed. As Hillary Rodham Clinton, who has so impressively taken on this monster issue, has put it, “good health is every American’s most cherished possession.”

Thus, the deeply personal nature of this social policy reform is at the root of the selling job that Clinton has only begun. While recent polls have shown that most Americans agree that health care needs change, it isn’t at all clear that most are ready for true overhaul. But overhaul is what Clinton is proposing, through six, as he put it, “guiding principles”: security, simplicity, savings, choice, quality and responsibility.

Right now, about 200 million Americans are insured, but a growing number fall into the category of under-insured for serious illness or injury. About 37 million have no insurance at all. And, paradoxically, while the numbers of uninsured grow, more and more is spent on health care--about $800 billion last year. Indeed, if such spending continues to outpace the rest of the economy, in the next 30 years health care will consume almost one-third of the gross national product. That’s totally absurd.

To deal with that, Clinton urges a national reform that is, in part, modeled after a very promising proposal that in large measure first surfaced here in California. He proposes a “managed competition” plan conceived by Stanford health economist Alain Enthoven and Minnesota physician Paul Ellwood and championed by California State Insurance Commissioner John Garamendi. It’s a tricky compromise between what exists today and the government “single-payer” approach of Canada.

In broad strokes, Clinton’s plan would ensure coverage for all Americans, although not immediately. Employers would contribute about 80%, workers about 20%, of a percentage of an employee’s paycheck as a premium. Even with a proposed tobacco tax, the plan appears to be underfunded for the estimated $441-billion costs from 1994 to 2000. That’s something Clinton and Congress must fix.

QUALITY QUESTION: One key principle cited in the President’s speech that needs far greater thought and debate is quality of care. So much of what goes on at a doctor’s office is subtle. Let’s hear more about what the President’s speech only touched upon: the likely sacrifice in store for the middle-class, well-insured family that will find choices more limited and direct costs higher than before; and the inevitable pressures that may pit quality against cost. It may be that Clinton was right in arguing that more efficiency would not necessarily decrease quality; however, surely more efficiency does not necessarily mean quality would be unaffected. This equation has to be watched carefully.

These are questions that must be asked as the nation embarks on the tough but necessary road to true health care reform. The President has certainly diagnosed a serious problem, and in principle the managed-competition approach to reform makes sense, in no little measure because it seems more politically doable than any of the alternative approaches. But underneath the broad principles lie those all-important details. That’s the next thing America needs to examine as this extraordinary reform effort takes further shape.